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9 <br /> APPLICATION FOR PERMIT <br /> r <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> I 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> IIPERM11 EXPIRES 1 YEAR FROM DATE ISSUM 1 C� <br /> (Complete in Triplicate) �`L' ` <br /> u, <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 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> g(Job Addiess 4 City —Lot Size/Acreage <br /> /Owner's Na Address r Phone <br /> j1�� t If <br /> V�(:ontr Addres � ;cense Phone <br /> TYPE OF ELL/PUMP: I NEW WELL ❑ LL REPLACEMENT ❑ DESTRUCTION Cl out of Service Well ❑ <br /> PUMP INSTALLATION 0 YSTEM REP R ❑ OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE LL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONS UCTION SPECIFICATIONS GAI <br /> C] Industrial ❑ Open Bottom ❑ Manteca Dia. i I Excavation Dia. of Well Casing <br /> El Domestic/Private ❑ Gravelii Pack ❑ Tracy T e of Cas g - Specifications <br /> I'I Public Ia Other Cl Delta epth of Grou Seal Type of Grout \ <br /> I I Irrigation �.Approx. Depth l I Eastern Surface Seal Ins lied by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter sling Material. & Depth <br /> Depth Filler Material b Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION f I REPAIR/ADDITION I 1 DESTRUCTIO (No septic system permitted if public sewer is <br /> vailable within 200 feet.) <br /> Installation will serve: Residence_ Commercial _ Other <br /> Number of living units: 11 Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg s Capacity., t No. Compartments ' <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line L <br /> 11 F <br /> LEACHING LINE 0 No's& Length of tines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> I� <br /> SEEPAGE PITS 11 Depth Size Numbef <br /> SUMPS Cl Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS © I1 '" <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 performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The appli dor all req) 'ad pecti s. Comp'1eto awing on rev r si <br /> ig d Title: Date: <br /> 1 F DEPARTMENT USE ONLY l <br /> Application Accepted by _J2 6A4 1�� - B <br /> Date _ Area <br /> c G <br /> Pit or Grout Inspection by I� Date Final Inspection b �C Data / ✓ <br /> Additional Comments: II F <br /> II <br /> Applicant – Return all copies to: Sam Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNTiDUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'N0. <br /> INFO <br /> F —7,1 <br /> ♦ EH 13-24 IREV.11 w 57 _ . <br /> EH 14-26 <br /> �i <br />