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--� �s.{APPL'I CATION FOR PERMIT—f <br /> SAN�JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION k " <br /> h 1601. E. HAZELTON •AVE. , PHONE (209)468-3420 <br /> 4 :; <br /> P 0 BOX 2009", STOCKTON, CA 95201 €° <br /> 1 PERMIT E%PIRES 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 work herein described. This T <br /> application is made in compliance with San Joaquin County Ordina a No. 549 and'1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. $ �, <br /> CA- <br /> Job Address _ ' t City "' 1 Lot Size/Acreage <br /> 1Z FS <br /> Owner's Name f��9 -- Address / '�' Phone <br /> Contractor i�� Yan►n41 _ _ 7�s1 �Add�e w, 1� 1 <br /> License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 17) DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION 13SYSTEM REPAIR M OTHER )< Ronitorin5 Well Ei <br /> + DISTANCE TO NEAREST: SEPTIC TANK f''� — SEWER LINES 0L DISPOSAL FLO. PROP. LINE S <br /> FOUNDATION } AGRICULTURE WELL OTHER WELL PITSISUMPSI Is! <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' <br /> f-1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> pSr04auwaelPrivate ❑ Gravel Pack Ll Tracy " Type of Casing Specifications <br /> I'I Public f.7 Other F1 Delta Depth of,Grout Seal Type of Grout <br /> ! I Irrigation —.Approx. Depth i I Eastern Surface Seat Installed by <br /> a <br /> Repair Work Done L7 Type of Pump H.P, State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> * Depth Filler Material ti Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I ! DESTRUCTION l I (No septic system permitted if public sewer is t <br /> available within 200 feet.i <br /> Installation will serve: Residence— Commercial T Other } <br /> Number of living.units: Number of bedrooms ' <br /> Character of soil.to"i depth of 3 feet: Water table depth <br /> SEPTIC TANK.. ❑ Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Wel!" ` Foundation Property Line t <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest;_ Well Foundation Property line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well 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 laws, and <br /> rules and regulations of the San Joaquin County a <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 t at in the performance of the work for which this permit is issued, I shall.amploy persons subject to work man's"compensa ,. <br /> tion laws of California:" s? <br /> The applicant must 11 for all r aired inspections. Complete drawing on Creverse side. <br /> Signed X Title: Ji"°r eU"lo ! r� �' _ Date: <br /> FOR DEf?.ARTMENT USE ONLY E <br /> Application Accepted by \ Date —� Are'a' <br /> Pit or Grout Inspection by h Date l`2 �'Z �: Final Inspection by Date <br /> Additional Comments;: <br /> Applicant Return all copies to: San Joaquin County Public Health <br /> Services, Favironmental'Realth-Permit/Services '✓ "� <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA '95201 <br /> FEE I AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. ? <br /> INFO', 7 CASH <br /> r EK 1 3-24 tREV.1/H 51 <br /> EH 14.201-793 <br />