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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 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXP I RES 1 YEAR FROM DATESS5 TEED <br /> (Complete in Triplicate) <br /> I <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. 51+9 and 186 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address City Lot Size/Acreage , <br /> x <br /> ` a `�o.YIQ " ,.24 s Phone r u <br /> Owner's Name Address � — <br /> t /) r - --"- �� License No. p Phone �K -S-�2 2-1 <br /> Contractor Itis/ Address <br /> TYPE OF WELL/PUMP: NE WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ l <br /> PUMP INSTALLATION ❑ SY TEM REP OTHER ❑ Monitoring Well k <br /> i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESDISPOSAL FLD. PROP. LINE k <br /> } <br /> a FOUNDATION AGRICULTURE W OTHER WELL-' - PITS/SUMPS <br /> INTENDED USE € TYPE OF WELL PROBLEM AREA C S UCTION SPECIFICATIONS ; <br /> 11 Industrial 1 ❑ Open Bottom ❑ Manteca ia. of ell Excavation Dia. of Well Casing t <br /> C7 Domestic/PrivateC] Gravel Pack C3 Tracy Type Casing Specifications <br /> a <br /> Il Public �' ;C7 Other' fl pelta Depth of Grout Seal Type of Grout <br /> o`; ) <br /> I I trngation Approx. Depth I I Easter Surfac Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Materiel & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1441-REPAIR/ADDITION i I DESTRUCTION I I INo septic-system_permitted.if,.public.sewer is <br /> available within 200 feet.) t <br /> Installation will serve: Residence_ Commercial her <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 - Capacity ?No, Compartments <br /> :. .P <br /> PKG. TREATMENT PLT. ❑ f_ ,ftp Method of Dispos <br /> Distance to nearest: Well oundation� � Pro rty Line ... ,- -. <br /> oe <br /> LEACHING LINE ClNo. & Length of li en s �i` VTotal N0 <br /> aL <br /> I FILTER BED F1 Distance.to nearest: Well Foundation Property Line f� <br /> r <br /> b SEEPAGE PITS 11 Depth �' Size. � _ ANbe <br /> r <br /> SUMPS LI Distance to nee 1: W611 Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application ar_id that the work will,be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San_Jpaquin County ,f <br /> Home'owner or licensed agent's signature certifies the following: "I certify that1n 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 pertorhiance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." ',; _4 y { �- <br /> The applicant si call fprpr <br /> equire inspections. Complete drawing ph reverse side. <br /> Signed r Title Date: <br /> RTMENT USE ONLY <br /> e p <br /> Application Accepted by �� �,"1 � .4 1-(11 M,�� Date L Area <br /> Pit or Grout Inspection by Date y Final Inspection by Date <br /> r Additional Comments: ` <br /> Applicant - Return a.11 copies to: Sass Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE INFO AMOUNT DUE. AMOUNT REMITTED. CK CASH RECEIVED BY DATE PERMIT'NO. <br /> . EH 13.24 IREV.I/n e1t0� L) 'Z 41-- . <br /> p <br /> EH—26 <br />