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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 16101 E. HAZELTON AVE. , PHONE (209)468-3420 <br />' P O BOR 2009, STOCKTON, CA 95201 <br /> �e Pw YEAR FROM DATE ED <br /> lEEJIIT EXPIRES 1 ■ <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 /> 4 n <br /> Job Address City S Lot Size/AcreageT <br /> Owner's Name' <br /> Address 2- �+`a`��vV[8 1^T-4 JJ- !f'n Phone <br /> Cpntractor.�4_ [3 �dt C- -Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION ❑ Out of Service Well D <br /> t PUMP INSTALLATION ❑ SYSTEM REPAIR, OTHER D Monitoring Well <br /> DISTANCE TO NEAREST:SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 111 Industrial ❑ Open Bottom ❑ Manteca - Dia. of Well Excavation Dia. of Well Casing <br /> f:) <br /> Domestic/Private ❑ Gravel Pack C3%Tracy .: } Type of Casing ' Specifications <br /> I'l Public El Other n Delta Depth of Grout Seal Type of Grout <br /> � s <br /> Iyrrigation Approx. Depth I astern Surface Seal installed by <br /> Repair Work Done Type of Pump/a✓ .H.P. ~- State Work Dane <br /> -,.,.Sealing-Material...&-Depth_ Z- <br /> Weilt�estruction ❑-.-=Well Diameter, �_ --- - <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION IJ INo septic system permitted if public sewer is <br /> 4, t available within 200 feet.M <br /> Installation will serve: Residence_ Commercial— Other f �: <br /> ' Number of,living units: Number of bedrooms j <br /> Character of sail to a depih of 3 feet: Water table depth i <br /> r SEPTIC TANK! 0 --Type/Mfg f Capacity -No. Compartments, <br /> PKG. TREATMENT PLT. ❑,- `4, ,�-.� f!� ,,.- . . :.� � '� ,,�Method of Disposal _ <br /> f Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED LI Distance to nearest: Well Foundation � Property Line <br /> ' SEEPAGE PITS 11 Depth Size Number <br /> SUMPS tl Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS L D Jr <br /> jl•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 r <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 taws 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'/omp nsa- <br /> tion laws Of Calif <br /> The applic must c I for all required i ctians omplete drawing o rse side. <br /> Signed Title: �C�� __ _ Date: <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by ��4�_�.a,��c.��-. - Date Area �- <br /> Pit or,Grout Inspection by Date_____ Final Inspection by , ! Date Z <br /> } <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave.. P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED I CK 4 RECEIVED BY DATE Pt RM17'110. <br /> INFO CASH <br /> + EN 13.24(REV.1/115} gs�oo l {�+ l�• l� !+� <br /> l EH 14.2e LL <br />