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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 3.601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BO% 2009, STOCKTON, CA 95201 11 <br /> li <br /> IRES 1 YEAR FRQM DATE ISEURDj� <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 Aealth Service t" r <br /> Job Address Ze aZ_, 50—, City Lot Size/Acreage <br /> 2 <br /> 5� 0 i X53 <br /> Owner's Name "' r.. Phone <br /> Contractor , . "r'a.'-Address"".._'-.� 'License No:"...- -^- i?hone-..." <br /> TYPE OF WELUPUMP:. NEW WELL D WELL REPLACEMENT ❑ DESTRUCTION ❑ out of Service-Well ❑ <br /> `PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER <br /> 10 !l' Monitoring Well D <br /> DISTANCE TO'NEAREST: SEPTIC TANK SEWI_R"CINES y DISPOSAL fLD, PROP: LINE <br /> i FOUNDATION 4 AGRICULTURE WELL OTHER WELLG - PITS/SUMPS _— <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIp.NS <br /> C7 Industrial 1 C1 Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing <br /> i <br /> C.l Domestic/Private D Gravel Pack 0 Tracy Type of Casing # Specifications <br /> I'] public Cl Other r n Delta f Depth of Grout Seal . Type of Grout <br /> I I Irrigation Approx. Depthf I 1 Eastern . Surface Seal Installed by } } <br /> Repair Work Done 0 Type of Pump <br /> State WorC Done <br /> ` H..P. lot I9 <br /> p Sealing Material & Depot <br /> Well Destruction 0 Well Diameter <br /> ` Depth Filler Material 6 Depth # <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRlADDITION I I DESTRUCTION No;saptic system-permitted if public sewer is <br /> EXPIT <br /> le DO feet.; <br /> i r I <br /> t <br /> 5 <br /> Installation will serve: Residence Commercial RE PWT 3ED <br /> Number of living units: Number of bedrooms f ! . <br /> Character of soil to a depth of 3 feet: t y ' �t;df�ble depth; <br /> SEPTIC TANK. r ❑ Type/Mfg p l r I $NO.,Cam artrnents <br /> _ Wi� gtficka <br /> PKG. TREATMENT PLT.❑ Disposal <br /> Distance to nearest: <br /> Well - _���i�iammil� � }-- -I <br /> u <br /> IE LEACHING LINE D No. & Length of lines Total lengthlsize <br /> FILTER BED /-0 Distance to nearW, Well ----Foundation Property Line 6 <br /> SEEPAGE PITS I L Depth Siie Number <br /> 4 <br /> SUMPS i LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ i 11 <br /> I hereby certify that I have prepared this application and that the work wilt be done in accordance with Sari.Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County a i <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, ! 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 he perfor ante of the work for which this permit is issued, I shall emptoy persons subject to workman's compensa- <br /> lion laws of California." <br /> The applicants all for req 'ed ins pe ions, Complete drawing o verse si <br /> Signed ; Title: ° DI ate: <br /> FOR DEPARTMENT USE ONLY9AF1C?—) <br /> Application Accepted by Date Area <br /> t � { <br /> Pit or Grout Inspection by Date Final Inspection by i Date <br /> /1Ja <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health t <br /> Services, Edvironmental Health Permit/Services I <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201, �3 <br /> FEE AMOUNT DUE AMOUNT REMITTED �CA5S RECEIVED BY "t E DATE PERMIT N0. <br /> INFO <br /> + EH 13-24(REV.t i H 5) <br /> 1�- �r <br /> 14-M <br /> i <br />