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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County public Health Services. / <br /> Job Address /0/415� L Lot Size/Acreage <br /> Owner's Name 4 /- r AQ �//�1 Address 'Phone <br /> Contractor _ �-- _ Address License No.Z 17 Phon ib <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT O DESTRUCTION ❑ Out of Service Well O <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O Monitoring Well O <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> O Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private O Gravel Pack O Tracy Type of Casing Specifications <br /> _ I"I Public f-7 Other f1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done L3Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth � N <br /> Depth Filler Material i Depth V <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION IU/DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence v Commercial_ Other <br /> Number of living units: __L Number gJ bedrooms 3 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. O Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 114""No. & Length of lines ' Total length/size .r <br /> FILTER BED ❑ Distance to nearest: Well Foundation s��/-.-- Property Line a? <br /> SEEPAGE PITS 0- Depth �S - `Sire. __6 P- �Ln'Numher <br /> SUMPS LI Distance to nearest: Well 0 / Foundation 4/1)/ Property Line dlo t <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agenfe signature.certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws:of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: 1 certify that in the performance of the work for which this permit is issued,.)shall employ persons subject to workman's compensa- <br /> tion laws of California." , <br /> ` The appli st.call for all r uir inspections. Complete drawing on vane side. <br /> Signed s Title: ,C•'delzL Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date <br /> Application <br /> / Area 1-2- <br /> _ �Py �� Ins <br /> 1 or Grout Inspection by Date Final Inspection by ��� <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE INFD AMOUNT,,vvDUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'^NO.' <br /> 1}24(REV.I/x51 1� �✓v ,� .OI '��,/ 1 <br /> EH:4-25 111 `-�� 111 <br />