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APPLICATION FOR PERMIT 3 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES i ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)4:68-5420 io P O BOR 2009, STOCKTON, CA 95201 ERP RES 1 YEAR FROM DATE ED 1 i (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San t Joaquin county Public Health Services. I r f 0 P �� City Lot Size/.Acreage Job Address i Phone s r Address :.. _ 'JOwner's•Name-� , �_� n-, P� License No. [O Phone d ! Contract r W Address r 'ter NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ I TYPE OF ELL-/PUMP:, c. OTHER ❑ Monitoring Well U PUMP INSTALLATION ❑ SYSTEM REPAIR L7 � SEWER LINES -- DISPOSAL FLD. , PROP. LINE �f! DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL PITS/SUMPS; FOUNDATION ; -- AGRICULTURE WELLF I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia of Well Casing (� p Open Bottom ❑ Manteca Dia. of Well Excavation O Cl Industrial Specifications Type of Casing [I Domestic./Private Cl Gravel Pack C1 Tracy� o• Depth of Grout Seal _ ;Type of Grout i'I Public S:1 Other (1 Oeltav it _.Approx. Depth I 1 Eastern ' ' >Surface Seal Installed by t I Irrigation l State Work Done Repair Work Done 0 Type of Pump H.P Sealing Material dr Depth it Well Destruction ❑ Well Diameter 'Filler Material & Depth Depthc system ! 'E TYPE OF SEPTIC WORK: NEW INSTALLATION I I`` EPAIR p01TION DESTRUCTION I I aNailabPelwithini20O feet.) it public sewer is j Install8tion will serve: Residence Commercial___7 Others? --- I� ts: _ Number of living uni, __ Number of be oms m '"rd . ,.v . Water tattle depth Character of soil to a depth of 3 feet; __• No. Compartments °6 f SEPTIC TANK. C1Type/Mfg PKG. TREATMENT PLT, C7 Capacity ` - Method of Disposal — Property Line Distance to nearest: Well -- ---r—'.f I ndation No. & Length of lines Q ' Tonal length/sizer k LEACHING LINE t r Property Line FILTER BED o Foundation P Y Ij i ❑ Distance to nea4;sY Well�—� � SEEPAGE PITS 11 Depth ` Size F lumber SUMPS Property Line Distance to nearest: t Well = Foundation I� s i DISPOSAL PONDS 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 rules and regulations of the San Joaquin County p Home owner or licensed agent's signature certifies the.following:_"_l certify-thatthe pertarmance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California," Contractor's hiring or sub-',contracting signature i certifies the•fotlowing: "I certify that in the-performance ofthe work for which this permit is issued, t shall employ persons subject to workman's compensa tion laws of California." _. spe The applica_ - t-call f Ire fired ed inspections. Complete drawing on reverse Signed Trtle: 3`J i Date: t ,' !� R PARTMENT USE ONLY Dace 2 Area Application Accepted by Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant — Return all copies to: San Joaquin County Public Health T a Services, Environmental Health Permit/Services ! µ 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 r s FEE CK ECjEgHZ7'NO. INFO AMOUNT DUE AMOUNT REMITTEDEH13-24IREY.I/h5S �EH;M26 hrx i