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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 <br /> P O SOX 2009, STOCKTON,.CA' 95201 <br /> " ggMIT EXP RES 1 YEAR FRQM D ED <br /> (Complete in Triplicate) <br /> Applieation .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 7Health Services. <br /> Job Address T `, - City Lot Size/Acreage <br /> 1 <br /> Owner's Name E, F Address �l� �� ti Phone <br /> J - <br /> r Contractor Address--e License Noce Phone <br /> TYPE OF WELLIPUMP' NEW WELL ❑ WELL REPLACEMENT_171 DESTRUCTION ❑ Out of service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C] OTHER ❑ Monitoring Well ❑ <br /> DISTANCE:TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> a` FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' <br /> i <br /> a n Iridusfrial ❑ Open Bottom ❑ Manteca Dia. of Well ExcavationMia. of Well Casing <br /> 1 C.1 Domestic I Private ❑ Gravel Pack E Tracy Type of Casing Specifications <br /> H Public; I1 Other , �>w f11Delta Depth of Grout Seal 'Type of Grout rr <br /> I I Irrigation —,-ApproK:Depth,- 1 1 Eastern Surface Seal Installed by ' <br /> Y <br /> Repair Work Done 0 Type(of Pump H.P. State Work Dona <br /> Well,Destruction ❑ Wel! Diarrietet`' Sealing Material & Depth <br /> f' Depth Filler Material 3 Depth 1' a <br /> I TYPE OF,SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION i I DESTRUCTION i I lNo septic system permitted it public sower is <br /> available within 200 feet. <br /> ti <br /> Installation will servA: Residence_ Coin`Merciaf; Other <br /> Number of living units: Number of bedrooms ' <br /> £. Character of soil io a depth of 3 feet: <br /> Water table depth <br /> SEPTIC.TANK. ;4�,, j ❑ TypelMfg: ` A-�� �- -- — Capacity^ No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT tT D f •T`y:` .k _�A, <br /> I Distance to nearest: Well Foundation 6 - Property Line <br /> LEACHING LINE No. & Lengthw�a(Ines a Tota! length/size / TT <br /> y, , <br /> FILTER.BED s'e Cl, Distance to nearest, Wel! - Foundation Property Line <br /> l SEEPAGE PITS; I! I Depth 7' Size Number <br /> i <br /> SUMP$ , Distance to nearest: Well Foundation_~_' "7- Property Line <br /> DISPOSAL PONDS to <br /> I hereby tenify 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 ani regulations of the Sarr,Joaquin. County <br /> Home owner or licensed lagent'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 /> t 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 lawsEof d�alifornla." <br /> The"applicant must call for all re` fired insPections.•Complete-.4fawing on reverse side. i <br /> Date: <br /> Signed Z;2 ^ 9� <br /> Signed ' Title: <br /> e -F(A, DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Fines Inspection by Date <br /> ' r <br /> t Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health ` <br /> s Services, Environmental-Health Permit/Services ; <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> } EH 5324iREV.t/nS) <br /> EH 8488 <br />