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APPLICATION FOR PERMIT <br /> BAN+JOAQUIN COUNTY PUBLIC <br /> ENVIRONMENTAL HEALTH ),VISION <br /> VIS ON VICES <br /> 1601 E. HAZELTON AVE, , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> EXP RES I Yis:sE R FR M DATE ;� <br /> (Complete in Triplicate) <br /> Application is hereby made tq Sea <br /> application is made in c Joaquin County for a permit t <br /> JoaQuin Cotmt °lth Sere ces.wIth San J o construct and/or install the work herein described. This <br /> Y Public Health Services, Oequin County Ordinance No. 549 and 1862 and the Rules and <br /> 1 $ <br /> Job Address Regulations of San <br /> City S <br /> Lot Size/Acreage <br /> Owner's Name — Q <br /> Aao►�ss` <br /> 1jD k Phone <br /> Contractor—�� � � I <br /> TYPE OF WELL/PUMP: Address (,o <br /> NEW WELL ❑ nse No. �Phone 3]- <br /> PUMP INSTALLATION ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR ❑ L1 <br /> —~—-- SEWER LINES OTHER ❑ Monitoring Well <br /> FOUNDATIONDISPOSAL FLD. € ❑ <br /> --�— AGRICULTURE WELL '-~--- PROP. LINE _____ <br /> INTENDED USE TYPE OF WELL OTHER WELL__,_�, PITS/SUMPS <br /> C7 lndust►ial PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Open Bottom ❑ Manteca <br /> C-] Domestic/Private Dia. of Well Excavation <br /> i1 Public r <br /> M Gravel Pack 0 Tracy. Type of Casing Dia. of Well Casing <br /> C7 Other ❑ Delta Specifications <br /> I ! irrigation Depth of Grout Seaf <br /> — Approx. Depth I I Eastern <br /> Repair Work Done LJ Type of Grout <br /> Surface Seal Installed by <br /> Type of Pump H.P. <br /> Well Destruction O Well Diameter State Work Done <br /> Sealing Material & Depth f <br /> Depth Filler Material & Depth t <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I ] ..,flEPAIII R/ADDITION f I DESTRUCTION ! (No septic system permitted if <br /> Installation will serve: Residence Public sewer is <br /> Commercial available within 20a feet.) <br /> �} <br /> Number of livingOther�--�� <br /> units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK. ❑ Typa/Mfg Water table depth d <br /> PKCt, TREATMENT PLT. (DCapacity��_�` No. Compartments <br /> Distance to nearest: Well Method of Disposal <br /> Foundation ` Property Line <br /> h <br /> LEACHING LINE 0 No. & Length of lines <br /> FILTER BED ❑ Distance to nearest: Well Total length/size <br /> Foundation�� property Line <br /> SEEPAGE PITS 1 ) Depth <br /> SUMPS Size Number I <br /> LI Distance to nearest: Well <br /> DISPOSAL PONDS ❑ Foundation..��� property Line <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, staJi <br /> y <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following, <br /> ify that in the <br /> employ any person in such manner as to became subject to workman's eompensadon laws of California."Contractor's hiring or subcontracti <br /> performance of the work for which this permit is issuecertifies the following: "I certify that in the performance of the work for which this ermit is issued, 1 shall em toripe apps of Californiall o P y persons subject to workman' <br /> The applicant must call for r <br /> Pe tons. Complete drawing on reverse side. <br /> Signed <br /> Title: g U <br /> Dace: <br /> FOR EPARTMENT USE ONLY <br /> Application Accepted by <br /> Date - l <br /> Pit or Grout inspection by Area <br /> Date Final Inspection by <br /> Additional Comments: F Date S 8 <br /> Applicant - Return all copies to: San J <br /> y Publ <br /> Health <br /> Servicces, Envi onmentaaliHealth Permit/Services Ct <br /> 1601 E. Hazelton Ave., P x 2oa9, Stockton, CA 95201TO <br /> FEE I AMOUNT DUE <br /> 'E 1NF0 AMOUNT REMITTED RECEIVED 8Y DATE PERMIT'NO. <br /> CASH �( <br /> 2�lREV.F�HS} r `_ d <br />