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APPLICATIO' OR 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 /> FRMTT &XPIBF� 1 YFs R FROM DATE ISStTED <br /> i (COMPlete in Triplicate) <br /> Application is hereby made to Sirs J Nin <br /> application is made in c County for a permit to construct and/or install the work herein described. This <br /> ortpliance with Ban Joaquin County Ordinance No.�549 and 862 snd the Rales <br /> Joaquin County Public Health Se ices, and Regulations of San <br /> Job Address ` <br /> L4 L City Lot Size/Acreage f <br /> � ii <br /> Owner's Name CLt� <br /> Address <br /> Phone <br /> ContractoAELL/PU4MP": =�;,�,­, <br /> Address ' <br /> TYPE OF EWELL '� License ha Phone a <br /> WELL REPLACEMENT ❑ DESTRUCTION ❑ put of Service We <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 11 Ll <br /> DISTANCE TO NEAREST: SEPTIC TANK � OTHER C. Monitoring well <br /> SEWER LINES DISPOSAL FLD. PROP„LINE <br /> FOUNDATION AGRICULTURE WELL <br /> INTENDED USE OTHER WELL PITS/SUMPS <br /> TYPE OF WELL PROBLEM AREA <br /> CI Industrial — -- -- CONSTRUCTION SPECIFICATIONS <br /> fl,� ❑ Own Softom ❑ Manteca Dia. of Well Excavation <br /> yc uomesticJPrivate ❑ Gravel Pack Die. of Well Casing <br /> I'!Public ❑ Tracy Type of Casing_ r <br /> 1-1 Other Specifications <br /> i I krrpation n Delta Depth of Grout Seal i Type of Grout <br /> —Approx. Depth I Eastern <br /> Repair Work pone Type of Surface Seal Installed by <br /> Pump <br /> " We11 Destruction ❑ H-P.� State Work bone <br /> Well Diameter —�— Sealing Material i Depth <br /> Depth Filler Material 6 Depth <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION I It <br /> REPAIR/ADDITION I.I QESTRUC7IQN I 1 IN septic sm ystepermitted if public Sewer is <br /> ~Installation will serve:,� r <br /> Commercial Residence available within 200 feet.) <br /> Number of living units: Number of T Other <br /> bedroomc <br /> Character of—sell to e_iiepftsiif:3–fief �`- <br /> SEPTIC TANK * 0 Type/Mfg Water table depth � <br /> PKG. TREATMENT PLT. L-) Capacity ` No. Compartments <br /> Method of Disposal <br /> 6 <br /> ' Distance to nearest: Well i <br /> Property Line. <br /> LEACHING LINE ! ❑. 116, b,Length Of tines – +� 1 <br /> FILTER BED ❑ Distance to +nearest: Total length/size <br /> Well Foundation <br /> t; _ Property Line <br /> SEEPAGE PITS ! 1 I Depth <br /> SUMPS —Size Number r <br /> Ll Distance to nearest, Well DISPOSAL PONDS p i Foundation Property Line ; <br /> I hereby certify that-I havere ` < <br /> p pared 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 Jo <br /> Home owner or licensed ant aquin County <br /> employ an s signature certifies the following:-I certify that in the performance of the work for which this <br /> Y Person in such rtnsnher as to become subject to workman's compensation taws of California." Contractor's hiring or sub-contracting sign n <br /> certifies the following: permit rs issued, I shall not <br /> 9 "I certify that in the Perform nice of the work for which this permit is issued,t shell employ 1 g 9 ure <br /> tion Isws of Callfornie?" D y persons subject to workmen' co <br /> The appl. nsa- <br /> st II for ell require spectio om <br /> piele drawing On rse side. <br /> Signed X <br /> Title: <br /> Date: <br /> USE <br /> Application Accepter)by ONLY <br /> Q <br /> Date _— { , Area <br /> 2' <br /> Pit or Grout Inspection by ` <br /> Date Final Inspection by <br /> Additional Comments: Date <br /> Applicant – Return e11 coplee to: San Joaquin County Public Health <br /> Services, Environmental Health permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 r <br /> FEEAMOUNT DUE f <br /> INFO � AMOUNT REMITTED CK <br /> (�)^/ <br /> ECASH RECEIVED BY DATE PERMIT'NO, <br /> H 13-24 IAEV,1/h 51�K �/\ <br /> EH 74.26 <br />