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APPLICATION FOR PERMIT /)z> <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 /> 1 <br /> PcMIT EMIRES 1 YEAR FROM DATES ~ ` ED <br /> (Complete in Triplicate) <br /> Application is hereby made•to,San Joaquin County-fora permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin Ccu_nty ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Cityle'.15el ILot Size/Acreage <br /> Job Address <br /> 0CfLL 6 14 1� Address S � I�QC3' `'J+�c� IF[c[ Phone <br /> 4Owner's Name �L� J� z Q <br /> �/�� ll c 't/I/h Address . -1 License No —Phone a <br /> Contractor Yl� AW <br /> TYPE OF WELLIPUMP:_ .. NEW•WELL ❑ WELL REPLACEMENT'S DESTRUCTION ❑ Out of Service Well <br /> OTHER ❑ 'Monitoring Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR 111i <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES ---r DISPOSAL FLO. POOP. LINE <br /> FOUNDATION AGRIGULTUREIWELL OTHER WELL PITSl5UMPS <br /> I INTENDED USE TYPE'OF,WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS' <br /> �[i Open Bottorir, ❑ Manteca Dia. of Well Excavation Dia.of Well Casing <br /> C1 Industrial <br /> Type of Casing ,? Specifications ` <br /> 'Domestic/Private ❑ Gravel Pack -L7 Tracy ` Tyge Grout <br /> C1 Public Cl Other Ii Delta Depth of Grout Seal � ^�tn h11 Irrigation /_T0_App(ox. Depth t I Eastern Surface Seal installed�Tr_� <br /> Repair Work Done ❑ Type of Pump •I — H•P- l — State Work Done <br /> Sealing Material & Depth ' e""_._ r <br /> Y Well Destruction ❑ Well Diameter Filler Material & Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I IaNai{septic le shit m rented it public sewer is <br /> Installation will serve: Residence Commercial— Other <br /> r <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 /> ElMethod of Disposal <br /> PKG. TREATMENT PLT. <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED Cly Distance to nearest: Well Foundation — Property Line ' <br /> SEEPAGE PITS �l I�DepthJ Size � _ Number �-... <br /> SUMPS U Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> r 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 tFie performance of the work for which this permit is issued, I shall not i <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting 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 /> E The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Sign Title: Date: <br /> ENT USE ONLY _ r <br /> L � <br /> plica ' T ccepied byY Date Are <br /> Pit Grou spection by r�- t— <br /> Date)-- Final inspection by 61-4 Dat���-� h <br /> Addi al 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 /> EEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'N0. <br /> INFO CASH <br /> . EH 13-24(REV.t i n 5) - k { <br /> r EH'Ze ! <br /> • f '' v <br />