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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> FgP RFS 1 YEAR FROM DA <br /> (Complete in Triplicate) <br /> Application is hereby rnade,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> r application is made in compliance with San Joaquin County Ordinance No, 549 and 1662 and the Rules and Regulations of San . � <br /> Joaquin County Public Health Services. r <br /> Lot Size/Acre <br /> Job Address <br /> 7 Ci age <br /> '• ' Address Phone� _ <br /> -Owrier's'Na � ( <br /> ? F •.'�• ` L'scense No. Z4 ZZ Phone -S <br /> Contract r Address <br /> �- NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well: ❑ <br /> TYPE OF WELL/PUMP. K »- st OTHER ❑ Monitoring Well C1 <br /> PUMP,,INSTALLATiON ❑ SYSTEM REPAIR D <br /> _ DISPOSAL FLD, PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER AGRICULTURE WELL OTHER WELL- PITS/SUMPS <br /> FOUNDATION <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> L, Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> i t f1 Domestic/Private 0 Gravel Pack- #=] Tracy Type of Casing <br /> _Depth-of-Grout-Seal - Type of Grout (} <br /> i'1 Public LI Other`` � 4^� n Delta <br /> ....J <br /> } <br /> 11 Irrigation _.Approz,'Depth' { I Eastern Surface Seai Installed by <br /> H.P.' State Work Done _ <br /> Repair Work Done C] Type of Pump > <br /> •„� Sealing Material $ Depth <br /> Well Destruction © Well Diameter & <br /> wN,'Filler Material &'Depth <br /> Depth , ' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATiON�I`1 REPAi ADDITION r DES�fiI�CTION^l I INa-se eric sy I�eZpermitted if Public sewer is <br /> Installation will serve: Residence Commercial. Othe 's <br /> _ , / <br /> Number of drooms` "" ' t <br /> Number at living units: <br /> Character of soil to a depth of 3 feet: r # Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> y 101 <br /> s ._ Method of Disposal <br /> PKG, TREATMENT PLT. ❑ Property Line <br /> Distance to nearest: Well Foundation <br /> x .s <br /> Total length/size <br /> LEACHING LINE Cl No. $ Length of lines, <br /> `+ll Properly Line <br /> FILTER BED e ❑4 Distance to nearest: WeEIFoundatiori " p y <br /> I! r <br /> umber <br /> SEEPAGE PITS Depth Size ,: w, <br /> Ll Distance to nearest: Weil "f Foundation " f" Property Line �= <br /> SUMPS <br /> DISPOSAL PONDS 0 <br /> with San Joaquin county ordinances, state laws, an <br /> I hereby certify that I have prepared this application and that the work will be done in accordaric . d <br /> rules and regulations of the San Joaquin`County ,, _._ - - s <br /> Home owner or licensed agent's signature certifies the following: l cel that in the performance At <br /> of th9 work for which this ring r permit ' sued, i shall signature <br /> employ any person in such manner as to become subject robe wo k for`wh ch this permit nsation is issued, I shall emplos of California." Ony perrsonarill lsubject to workrnan�lscompsnsa- <br /> certifies the following:"I certify that in the performance of ;` <br /> tion laws of California." } 'k <br /> The applican t call f r ifed inspections.;Complete drawing on reverse s' e. _ <br /> Signed <br /> Title: Date: <br /> 4r <br /> FOR DEPARTMENT USE ONLY <br /> � Date Area <br /> Application Accepted by <br /> ate D �Final Inspec[ion,by <br /> bate <br /> L �P]t or Grout Inspection y � <br /> (/Additional 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 /> FEECK ' R£C81VE0 B :1 OATS PERMIT'NO. <br /> INFO *AMOUNTE AMOUNT REMITTED CASH m <br /> EN 13,24 Illi M 5) <br /> i + '� Y /� <br /> EH£4.211 <br />