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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 1 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE 1SSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or Install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. r� <br /> Job Address 2 2 // OCity Lot Slze/Acreage <br /> Owner's Name 'v�N�L Address ��ML Phone <br /> Contractor `' � <br /> C � Address ILe U � 7"J AN-0 License No. �� <� Phone L 6J <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <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 /> Ci Industrial ❑ Open Bottom ❑ Manteca Dia- o1 Well Excavation Dia. of Well Casing <br /> Ll Domestic/Private ❑ Gravel Pack O Tracy Type of Casing Specifications <br /> 1"I Public 1.1 Other 11 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 U Type of Pump N.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth Filler Materia i Depth � <br /> 1� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I DESTRUCTION 11 (No sapliC system permitted if public sewer is <br /> ,/ available within 200 lest.) <br /> Installation will serve: Residence I, Commercial _ Other <br /> Number of living units: I Number of bedrooms_2 <br /> Character of soil to a dept of 3 feet: t� <br /> SEPTIC TANK dept <br /> Y N<-CA�� L Ca Water table depth _ <br /> PacitY 2 LO No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal C_ <br /> Distance to nearest: Well Foundation Property Line <br /> t <br /> LEACHING LINE No. 8 Length of lines O Total longth/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> S IJ SZcr� (i j i t( u e (r{c v <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS LI Distance to nearest: Wet Foundation Property Line <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 tawsand <br /> rules and regulations of the San Joaquin County, , <br /> Home owner or licensed agent's 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: "I certify that in the performance of the work for which this permit is issued,I shalt employ persons subject to workman's compensa <br /> tion laws of California." <br /> The applicant must call for all required in ctions. Complete drawing on reverse side. <br /> Signed X Title: Date: <br /> b j z <br /> /l DEPARTMENT USE ONLY <br /> Application Accepted by - —I E` { <br /> \v Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant — Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Ratelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> CASH RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> i 1124 IREV.ri nst ./• <br /> EH A-26 <br />