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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 07 1P <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> Exp RES 1 YEAR FROM D TE <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a perms to construct and/or install the work herein described. This I <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 /> �. �� � City Lot Size/Acreage J <br /> Job Address <br /> � <br /> es <br /> Owner's Name t <br /> T' Address Phone <br /> Contractor <br /> >Address — License No. Phone <br /> TYPE OF WELUPUMP. NEW WELL WELL REPLACEMENTL7 DESTiRS1�T�IION ❑ Out of Service Well ❑ <br /> BOTHER ❑ Monitoring/Well t� <br /> j�f PUMP INSTALLATI SYSTEM REPAIR rf <br /> �Dl �_ PROP. LINEDISTANCE TO NEAREST: SEPTIC TANK SEWER LINES AL FLO. I FOUNDATION — AGRICULTURE WELL r WELL PITSlSUMPS !L�� <br /> INTENDED USE .A ,TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI S <br /> _ I <br /> C7 Industrial f .O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casino; <br /> Ali T e of Casing Specifications <br /> Y9DomesticJPrivate ravel Pack 0 Tracy yp <br /> ` i. Other n Delta Depth of Grout Seal Ty e of Grout <br /> 41 Public i <br /> �.� ,, .ry - <br /> i ( Irrigation �qC Approx, Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑r Type of Pump H.P. State Work Done <br /> Sealing Material Depth <br /> Well Destruction ❑ Welt Diameter <br /> & <br /> i Depth Filler Materiel & Depth <br /> TYPE OF SEPTIC WORK: NEW'INSTALLATION l 1 REPAiRIADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> i 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: T Water table depth_, <br /> t Capacity No. Compartments <br /> SEPTIC TANK Ell TypeJMig <br /> II PKG. TREATMENT PLT. D Method of Disposal <br /> Distance to nearest`;� 'r Well Foundation Property Line <br /> k <br /> LEACHING LINE L-) No. VLengttrof lines ` f Total lengthisize <br /> FILTER BED ❑ Distance to neatest" Nell -Foundation Property Line <br /> 1 ;t' j <br /> SEEPAGE PITS I I Depth y )Size+ r Number <br /> SUMPS LI�Oistarice to nearest:,' rWell �- --Foundation Property Line <br /> - <br /> DISPOSAL PONDS 0 <br /> hereby certify that I have prepared this applicatlon,and that the work_v ill be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County, - <br /> the following; rl certify that in the performance of the work for which this permit is issued, I shall not <br /> Hams owner or licensed agent's signature certifies <br /> employ any person in such manner as to becom,a,sutiject 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 /> The applican u all equir I cf Complete drawing on rev se side. <br /> Signed Title• Date: <br /> { ;F R DEPARTMENT USE NLY <br /> Date Area <br /> Application Accepted by <br /> J ' `-_�*Date VI Final Inspection by <br /> Oats <br /> Pit or Grout Inspection by _ s 4 <br /> Additional Comments: <br /> Applicant - Return sll copies to: San Joaquinotulty Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hatelton Ave., F 0 Box 2009, Stockton, CA 95201 <br /> k FEE AMOUNT pUE AM T REMITTED CASH CK 0 RECEIVED BY DATE PERMIT'NO. <br /> r INFO9 D _ 7777 <br /> i . EH 13-24(REV. <br /> EH:x•26 � " v <br />