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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 /> r P 0 BOX 2009, STOCKTON, CA 95201 <br /> EXPIRES 1 YEAR FROM DATE-IM—ED <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 Servlces. <br /> R 2 City s s L Lot Size/Acreage <br /> Job Address <br /> �P,[;T7J� Address Phone ! �-r"� 5 (1Z1 <br /> Owner's Name a <br /> 1` (7 <br /> License N0.3?23 8 —Phon -ZZs <br /> Contractor <br /> �1� t Address <br /> 11 <br /> OTHER El Monitoring Well <br /> TYPE OF WELL/PUMP: NEW WEL WELL REPLACEMENT ❑ DESTRUCTION Out of Service Well Lf <br /> PUMP INSTALLATION SYSTEM REPAIR E] <br /> 1 � DISPOSAL FLD.� PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> FOUNDATION AGRICULTURE WELL OTHER WELD- PITS/SUMPS <br /> NSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CO <br /> /'>` Dia. of Well Casing <br /> n industrial © Open Bottom ❑ Manteca Dia. of Well Excavation._� _Tracy C <br /> XDomestic/Private Gravel Pack L7 <br /> Type of Casing V Specifications <br /> Depth of Grout Seal l�a� Type of Grout <br /> I'l Public' (-I Other n Delta ON 2 <br /> I i Irrigation "�jA Approx. Depth I I Eastern Surf ce Seal Installed by <br /> / _ State Work Done��'Q <br /> Repair Work Done L7 Type of Pump Setting Material Depth <br /> I Well Destruction ❑ Well Diameter 115 Filler Material r: Depth <br /> Depth <br /> TYPE OF.SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION 1 1 DESTRUCTION I I availableNo lw thin 200 stem feet.) if public sewer is <br /> Installation will serve: Residence�� Commercial_ Other <br /> f <br /> N Number of living units: Number of bedrooms — Water table depth <br /> �. Charactet of soil to a depth of 3 feet: No, Compartments <br /> SEPTIC TANK ❑ Type/Mfg Capacity <br /> I <br /> PKG. TRMethod of Disposal <br /> i. EATMENT PLT.❑ t <br /> Distance to nearest: Well Foundation Property Line k <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> , C <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line _ <br /> SEEPAGE PITS l'1 Depth Size Number - <br /> CI Distance to nearest: Well Foundation Property Line <br /> I SUMPS <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 /> rulas•°and regulations of the San Joaquin County <br /> HtSme owner or licensed agent's signature certifies the}oflowing: "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 <br /> o�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 peksossubci to-workman's compensa <br /> tion laws of California." 6. <br /> The applicant must II for all required inspections. Complete drawing on reverse side. <br /> y Date: `�- <br /> Signed a Title: 0:!6! ^ ¢ - <br /> i r <br /> FOR DEPARTMENT USE ONLY <br /> i Date n Area <br /> Application Accepted by ,, <br /> A�ci r � _— Date r <br /> Pit or Grout Inspection by .Date Final tnspection by`_ I i <br /> Additional Comments: <br /> k Applicant - Return all copies to: San Joaquin County Public Healt}tr , , --. k >. <br /> # Services, Environmental He"ellth permit/Services p <br /> { tt 1641 E. Hazelton Ave., F 0 Box 2009, Stockton,-CA 95201 <br /> r <br /> PEE AMOUNT DUE AMOUNT REMITTED G RECEIVED BY OATS jPE1A1EMI1'NO.1NF0EH 13-24[ACV.+/++ss 1 '� X ♦�3 <br /> EH 61.29 .- <br />