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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 0 BO.Y. 2009, STOCKTON, CA 95201 <br /> pERMIX IRES 1 YEAR FROM DATE SD <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 1$62 and the Rules and Regulations of San <br /> Joaquin County <br /> Public Health Services. <br /> Job Address //�lL I PCO City Lot Size/Acreage <br /> 41' <br /> Owner's Name <br /> _ Address 7`{ q ��C� A� Phone 7 <br /> Contractor Address License No.? Phone_ <br /> t <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WEL REPLACE T ❑ DESTRUCTION ❑ Out of Service Well ❑ i <br /> PUMP INSTALLATION ❑ S STEM PAIR D OTHER ❑ <br /> Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE L OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CO UCTION SPECIFICATIONS <br /> D Industrial El Open Bottom ❑ Manteca D' of ell Excavation Ria. of Well Casing j <br /> [I DomesticlPrivate 0 Gravel Pack L7 Tracy ype of C ing Specifications <br /> F) Public I:1 Other n Delta Depth of Gr ut Seal Type of Grout <br /> I I Irrigation .Approx. Depth I I Eastern Surface Seal nstalled by <br /> Repair Work Done U Type of Pump H S=Wofk <br /> Well Destruction ❑ Well Diameter soling Material Depth <br /> Depth Filler Material S Depth <br /> TYPE OF SEPTIC WORK: NEW INS7A_ <br /> TION I 1 REPAIRIADDITION I 1 DESTRUCTION 11 (No septic system permitted if public sewer is <br /> i _.available,within 200 feet.I <br /> Installation will serve: Residence— ommercial_ Other <br /> Number of living units: .,, Number of bedrooms �~ <br /> Character of soil to a depth of 3 feet: Water table depth 2 S <br /> o _ 00 No. Compartments <br /> i SEPTIC TANK. ❑ Type/Mfg Capacity <br /> PKG. TREATMENT PLT. 0 rrf e— Method of Disposal <br /> J_ Distance to nearest: <br /> Well Foundation �.5 Property Line <br /> LEACHING LINE No. & Length of lines Tot Llength/size_ <br /> FILTER BED ❑ Distance to nearest: Wall gra -- Foundatian_�-� 7 Property Line <br /> k <br /> EEPAGE PITS I,/�epth Size NumberSUL Distance to nearest: Wel! �o ound cion Property Line <br /> DIAL PONDS D 2— JC i7 4 <br /> I <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 Calif `" ` ` ' l <br /> `The applican calf ar a' li required inspections. Complete drawing on reverse side. <br /> ((\Signed v7za/ Title: AASX Date: <br /> / FO DEPARTMENT USE ONLY <br /> Application Accepted by Date L Are <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Servicea <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY GATE PERMIT NO. <br /> INFO / p <br /> • EH 21 r1i£V.tiw6i 1 0 /0/S <br /> EH 74114-20 � <br />