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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)46$-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PEUIT EXPIRES 1 YEAR FROM DATE <br /> (Complete in Triplicate) <br /> Application is hereby trade 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 HealthServices. <br /> pp �+,� <br /> l ! ` Job Address 1"t-11LOP Cit y� �` Jo Lot Size/Acreage <br /> Address �� � `102S <br /> �. Contractor Address License N Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Out of Service We11 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR © OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER'LIN£S DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ! ; <br /> n Industrial ❑ Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Lo <br /> 1-1 Domesticl Private 0 Gravel Pack ❑ Tracy -Type of Casing Specifications <br /> U1 Public Ll Other Cl Delta Depth of Grout Seal Type of Grout (�_SdtK Aq 11L <br /> i I Irrigation __ Approx. Depth l I Eastern urface Seal Installed by_ - �QJsI�Yh F!s'•_f.�. <br /> Repair Work Done L] Type of Pump SV6 H.P. State Work Done <br /> Well Destruction Well Diameter t _. Sealing Material & Depth -� <br /> Depth Filler Material & Depth <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION l I REPAIRIADDI ON I I DESTRUCT! I I INo septic system permitted it public sewer is \ <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: A A Water table depth <br /> SEPTIC TANK p Type/Mfg p city No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Fou alio Property Line <br /> LEACHING UNE E) No. & Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Wel! / td <br /> 1_ Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size umbar �^ <br /> U. <br /> SUMPS Cl Distance to nearest: Well Foundation Property Line C <br /> DISPOSAL PONDS ❑ 1 <br /> I 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 agent's signature oertifies 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 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> �1/The applicanntt�muststrcall for Il r quired inspections. Complete drawing on rarse side, �] E3 JqC) <br /> -Signed X /! Title: _`Lfo Cir/S� / /��I�'&s'' '`�dTs: v <br /> O PARTMENT USE ONLY <br /> Application Accepted byOLS-: Date Area <br /> } Pit or Grout Inspection by Date Final Inspection by Date [d <br /> Additional Comments: 4 Gs , 0 Av`L— <br /> Applicant Return all copies to: San Joaquin County Public Health, <br /> Services. Environmental Health Permit/Services <br /> i 1601 E. Hazelton Ave., P 0 Box 2009, Stockton. CA 95201 <br /> FEE UNT DUE AMOUNT REMITTED CASH. <br /> RECEIVED BY DATE PERMIT'NO, <br /> t <br /> INFO <br /> ♦ EMI3- <br /> IAEY. /8 5) <br /> EH 14.21B <br /> 4 <br />