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l _ <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES qS <br /> �` <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 � bLoofv, <br /> P O BOX 2009, STOCKTON, CA 95201 , ,r <br /> r � <br /> PERMIT EXPIRES 1, YEAR FROM ]ATE ISSUED +�►lf <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 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Se <br /> r <br /> j( Joh Address bel t Lot Size/Acreage <br /> ' S WD. , t-�Zl2 <br /> - k�o <br /> �( Owner's Name Address Phone <br /> r t <br /> x Contracior Address_ ` �_\]L� !\ NX License No. Phone <br /> TYPE OF W /PUMP: NEWWELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> d. <br /> MP INSTALLATION C1 SYSTEM REPAIR ❑ OTHER C1Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTI SEWER LINES DISPOSAL FLD. OP. LINE <br /> € FOUNDATION AGRICULTURE WELL OTHER WE PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM CONSTRUCTION (CATIONS <br /> Cl Industrial t ❑ Open_Bottom �^ ❑ Manteca D1 . Excavation _Dia._okWell-Casing <br /> [7 Domestic/Private ❑ Gravel Pack L7 Tracy ype of Casr Specifications <br /> i'I Public (-I Other " 1� [� Depth of Grout Seal Type o} Grout <br /> 11 irrigation _ Approx. ._...I I Eastern-- Surface Seal Installed-by�- <br /> Repair Work Done 0 Pump H.P. State Work Do <br /> Well Destructio Well Diameter Sealing Material & Depth 3 <br /> _ Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTIO (No septic system permitted it public sewer is <br /> t available within 200 feet.) � <br /> Installation will serve: Residence__Cornm6rcial_ Other <br /> Number of living units: Number of bedrooms x <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK.: ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> , <br /> r <br /> LEACHING LINE D No. & Length of linesw _ Total length/size ' <br /> FILTER BED CJ Distance to nearest: Wall Foundation »....- Property Line k <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS .t Cl Distance to nearest: Well Foundation � Property Line <br /> DISPOSAL PONDS 0 <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 perform ce of the wor or which this permit is issued, I shall employ to workman'scompensa- <br /> tion laws of CalifornJ — - _.y persons s_.. _ _.. r_ .,.-. ,R <br /> i <br /> The applic us all for all req 'r d i mplete r ing on verse side., - <br /> YSigne Title: Date: <br /> - r <br /> DEPARTMENT USE_ ONLY ,ms's <br /> Application Accepted by Date _ Area <br /> •_„_ <br /> a <br /> Pit or Grout Inspection by Date Final Inspection b� ���_ Date Z -� <br /> Additional Comments: _ - 91 <br /> Applicant - Retura all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> r 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> + EM 13.241REv.sins)SD � <br />