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r APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)465-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES„ ] YEAR FRQM 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 <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 Health Services. <br /> Job Address City �/ Lot Size/Acreage <br /> Owner's Name tieJ'L��Qltess 6/ � <br /> Phone <br /> Contractor Address 6 Z8 1 C5 License No. JS Phone-77-0: �r- f� <br /> TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well' ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR OTHP I NLMonitoring well <br /> K <br /> DISTANCE TO NEAREST: SEPTIC TANSEWER LINES DISPOSAL FLD. P ��I� <br /> FOUNDATION _ �_ AGRICULTURE WELL „�_ OTHER WELL PITS/Sum PS4460-z <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS � <br /> n Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> KDomestic/Private ❑ Gravel Pack Cj Tracy Type of Casing Specifications. - ... <br /> FI Public -`!`i Other n Delta Depth of Grout Seal Tree of.Gaut - <br /> _._�W <br /> I Irrigation V_i,5pprox. Depth I I Eastern Surface Seal Installed by" 146 % (?uar <br /> Repair Work Done U Type of Pump H.P. <br /> State Work Done <br /> Well Destruction 0 Well Diameter Sealing,Material & Depth i <br /> Depth Filler Material & Depth `^ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I } DESTRUCTION l I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> installation will serve: Residence— Commercial^ Other r� <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg pacify No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: W .Foundation Property Line <br /> LEACHING LINE L❑ No. & Length Ines Total length/size <br /> FILTER BED ❑ Distance nearest: Welt Foundation Property Line <br /> SEEPAGE PITS 11 epth Size _ Number <br /> SUMPS 1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL POND ❑ <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, anZl� ' <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 /> 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 /> v� 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 compansa <br /> tion laws of Californi ' <br /> The applicant must a or uired in ctio omplete drawing on reverse side, <br /> Signed <br /> Ito: Date: <br /> DEPARTMENT USE ONLY <br /> Application Accepted by Data_. bra ^� Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: ,}k­r 9 <br /> Applicant - Return all copies to: San Joaquin County Public Healthy i <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE gMOVNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH f� <br /> + 151113.2{tl1EY.tinS) <br /> 130t��70L�": <br /> 15H 14-26 •�1 <br />