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n <br /> APPLICATION FOR PERMIT <br /> SAN J'OAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 <br /> P 0 BOR 2009, STOCKTON, CA 95201 <br /> ,PRUMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> k <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??Publics/Health ervices <br /> J71 b v city / 3 <br /> Job Address � Lot Size/Acreage � <br /> -- �-- <br /> `` r Phone <br /> Owner's Name"' Address <br /> f� Q <br /> I � tA 5 J7 r t �`'iw=�4k <br /> icense No.�Phone <br /> Contractor (sk ^ C Mess <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT EJ DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> s <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS — <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> P Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications <br /> FI Public Cl Other r n Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation _..Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. IState Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth V <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 EPAIfa DITION DESTRUCTION I I INo septic system permitted it public sewer is <br /> ( available within 200 feet.) <br /> Installation will serve: <br /> Relidence, Commercial Other <br /> Number of living units: Num er of dr oms <br /> Character of soil to a depth of 3 feet: O Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> j PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well ,'Foundation Property Line <br /> LEACHING LINE No. & Length of lines I u Total length/size <br /> FILTER BED Cl Distance to nearest: Well 4 Foundation J 0 --- Property Line <br /> ) SEEPAGE PITS 14� Depth Size Number �= <br /> 70 <br /> SUMPS 1:1 Distance to nearest: Well ZOS Foundation 1AP ee Property Line S r <br /> DISPOSAL PONDS ❑ 7 } <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 /> 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 /> +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 us call for II required inspections. Complete drawing on reverse side. g <br /> Signed X Title: ��� Dater/ / o <br /> >~. R DEPARTMENT USE ONLY " <br /> 4 <br /> Application Accepted by ... Date Area <br /> Pit or Grout Inspection /by,� Date Final Inspection by Data OQ <br /> Additional Comments: <br /> i Applicant — Return all copies to: San Joaquin County Public Health ) W, <br /> r Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY PATE PERMIT NO. <br /> INFO CASH <br /> . EH13-24(REV.r/K51 �� <br /> ' EH 14.7e <br />