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h <br /> APPLICAT1-6&,.F0a PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIC <br /> ENVIRONMENTAL HEALTH DIVISION ���� , U, � <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-342 <br /> p O BOX 2009, STOCKTON, CA 95201 MAY 2 0 1991_ALTH <br /> c" iRONNAENITAL 1-4,E <br /> E%P RES 1 YEAR FROM DA <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 i <br /> application in made in compliance vith San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Sery ces. // a <br /> � ' � Cty Lot Size/Acreage <br /> Job Address � : ff <br /> Phone <br /> Owner's Name s <br /> --� 111 <br /> C n ra s <br /> ce se'No. ho <br /> � =5�—Pne <br /> NEW WELL ❑ WELL.REPLACEMENT DESTRUCTION ❑ Out of Service Well L`1 <br /> TYPE OF WELL/PUMP: OTHER ❑ Monitoring Well <br /> PUMP 1NSTAL1.ATl SYSTEM REPAIR C7 <br /> // SEWER LINES _ DISPOSAL FLD, PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ` <br /> Dia of Well Casing <br /> C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation specifications <br /> estic/Private ❑ Gravel Pack E3Tracy Type of Casing <br /> {'1 Public to Other <br /> fl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —Approx. Depth l ast rn /Surface Seal Installed by <br /> of Pum H.P. State Work Do r <br /> Repair Work Done L7_ Type Sealing Material & Depth T <br /> Well Destruction _ ❑ Welt Diameter Piller Material & Depths <br /> Depth <br /> INSTALLATION I i REPAIR <br /> IADDITION <br /> l I DESTRUCTION I i INo septic system permitted if public sewer is <br /> TYPE OF SEPTIC WORK: NEW available within 200 feet.] <br /> -_Installation will,serve:Z Residence ~Commercial.�=-7 Other <br /> ''—/Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK C] TypelMfg <br /> Capacity— No.'Compartments <br /> v. <br /> Method of Disposal.., - <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well f=oundation Property Line-- <br /> LEACHING LINE ❑ No. & Length of lines Total length/size ' <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property line <br /> f <br /> SEEPAGE PITS I I <br /> �-- TDepth <br /> Size- -- <br /> Foundation NumberP_ro artYLine <br /> SUMPS Ll. Dis ce to nearest: Well <br /> — <br /> DISPOSAL PONDS ❑ H <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 /> k 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 /> E tion laws o1 California " <br /> The applica m t c f r equir d inspections. Complete drawing on rev r side. <br /> Titie Date: <br /> fined <br /> OR DEPARTMENT USE ONLY I <br /> Date r a <br /> Application Accepted by Z <br /> Vr <br /> Pit or Grout inspection by <br /> Date — Final Inspection by.1 ` Date <br /> Additional Comments: <br /> Applicant — Return all copies to: San Joaquin County Public Health 4,� <br /> Services, Environmental Health Permit/Services <br /> I 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> t <br /> FEE CK RECEIVEpBY DATE PERMIT'NO. <br /> INFO AMOUNT D#JE A/MJOUNT REMITTED CASH <br /> . £H 13-24IFtEV.1/RSl �� �� <br /> EH 94.28 <br />