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• <br /> 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 O BOX 2009, STOCKTON, CA 95201 <br /> EXPIRESPERMIT 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby mede.to San Joaquin County for a permit to construct and/or inatall the work herein described. This <br /> + application in made'in compliance with Ban Joaquin County Ordinance No. 549 and 1862 and he %les and Regulations of San <br /> Joaquin County Public Health rvices. - /J pp <br /> Job Address ' City Lot ice-/Acreage <br /> s. �fei:srfYS7ne- ; /, C Address r-7 S �. �' Phone <br /> Contract - Address�r LJu X / License No. 37!Z�G Phone ��b Sl D.y <br /> STYPE;DF-WELD PUMP:f-ft;Ae'/,) - NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCT10N,0 Out of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR C t-t� �" i- Monitoring Well <br /> %�J,; L�.I 9.�,f i1+i,� i J_:OTHERt.O s,,.Md t7 <br /> DISTANCE TO NEAREST: SEPTIC TANK —.SEWER-LINES -------- nISPOSAL FLD. - - PH.OP LLINE� <br /> FOUNDATION AGRICULTUR1-W,ELL OTHER WELLS PITS/SUMPS <br /> J,j_i 1NTENDFD USEja � vT'YPE-OF WELL PROBLEM AREA CONSTRUCTION-SPECIFICATIONS <br /> I <br /> ] Industrial O Open Bottom ❑ Manteca Die'of Well Excavatib_rf` Dia. of Well Casing <br /> Cl Domestic/Private C Gravel Pack ❑ Tracy Type of Casing �� g r' s <br /> pecifications <br /> I': Public 1T�Othnr [l Delta "­---Depth-bf-Gioal- ;6Typ 'ol Grout <br /> I I Irrigation L_q� <br /> pprox. D'epth'�,.1 I Eastern Surf Soul Ihstelied by <br /> Repair Work Done ❑ Type of Pump :r H'P, Sate Work Gone — <br /> .k a <br /> Well Destruction ❑ Well Diameter Sealing llaterial'i Depth <br /> Depth Fills Material i Depth <br /> i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I t REPAIR/ADDITION DESTRUCTION I I INo septic system permitted it public sewer is <br /> lI available-within 200 feet.; <br /> Installation will serve: Residence`! Commercial cher <br /> Number of living units: �t Number of b o ms �. <br /> Character of soil to a depth of 3 feet: Water table depthILAQ t <br /> SEPTIC TANK ` Type/Mfg Capacity 'No. Compartments <br /> PKC. TREATMENT PLT. ❑ I t <br /> CT / =Method of Disposal <br /> Distance to nearest: Well J(1 Foundation Property Line S t <br /> 1 .r <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance toynearest. Well Foundation Property line <br /> to <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS ' <br /> LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ i EA <br /> I hereby certify that I have prepared this a r <br /> p County 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 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 /> __ empioy_any person in such-manner as to become subject to workman's compensation.laws <br /> certifies California; Contracto.t's Airing or_sut}contracting-signature__ <br /> cert;}les the following: "I certify that in the performance of the work for which this permit is issued,I shall employ persona subject to workman's compensa- <br /> tion laws of California." 11 y <br /> Thea applicant t call for a ui ins6 <br /> pP Q pections. Complete drawing'on reverse sid x <br /> Signed X Title: <br /> 2(�Z <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by el Da�w Date `�J L� _ 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 gN <br /> 1601 E. Hazelton Ave-, P 0 Box 2009, Stockton, CA 95201 <br /> J <br /> FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED 8Y DATE PERMIT NO. <br /> INFO CASH <br /> EH.21(REV.rrnei �� 1 �/9 <br /> FH tt-?.d �1 J-- <br />