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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRON1dENTAL HEALTH DIVISION <br /> 1001 T. gAZELTON AVE. . PHONE (209)468--3420 <br /> P O BOX 2009, STOCgTON, CA 95201 <br /> JNAMLT <br /> IRE 1 YEAR FROG DATE I SU , <br /> (Complete in Triplicate) <br /> in <br /> is hereby made,to San Joaquin County for a permit to ne eenstruct No. 549 -and1862thee vork Rules andeRegulationsdof Sans <br /> Applications <br /> County Ordinrur <br /> application is made in compliance with San Joaquin <br /> Joaquin County Public Health�Services. <br /> City �' T'oN Lot Size/Acreage <br /> Job Address � + <br /> t' Phone <br /> Address <br /> Owner's flame <br /> (s E �9`7I. �� Phone 3 7 <br /> ` CvROv ,A Litense No. <br /> ConttacC, Address tor WELL REPLACEMENT ❑ DESTRUCTION ❑ out of Service Neil L) <br /> TYPE OF WELLIPUMP: NEW WELL L C3OTHER 13Monitoring Well <br /> Er <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR , <br /> SEWER LINES — - DISPOSAL FLO. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK � OTHER WELL— PITS/SUMPS <br /> FOUNDATION ._ AGRICULTURE WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> Dia. of Well Excavation S <br /> Cl Industrial ❑ Open Bottom C3 Manteca � Specifications <br /> ❑ Tracy Type of Casing -54t4 Pjc +� <br /> C.) Domestic/private ❑ Gravel Pack Depth of Grout Seal Type of Grout <br /> !1 Other I l Delta <br /> i I'I Public Surface Seal Instated by <br /> I I Irrigation —Approx. Depth l I Eastern State Work Done _ <br /> of Pump H.P. <br /> Repair Work Done U Type Sealing Material & Depth <br /> Well Destruction ❑ Well Diameter �---�— Filler Material & Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW tN5TALLATION t 1 REPAIR/ADDITION l I DESTRUCTION I 1 alvailabe within 200 feeto septic system per i.Ied it public sewer is <br /> Installation will serve: Residence Commercial, Other r� <br /> Number of living units: Number of bedrooms. _..— Water table depth <br /> Character of soil to a depth of 3 feet: Capacity No. Compartments <br /> SEPTIC TANK ❑ TylelMfg Method of,Disposal <br /> PKG.-TREATMENT PLT.❑ Foundation� Property Line <br /> Distance to nearest: Well <br /> Total length/size <br /> LEACHING LINE 0 No. & Length of lines Property Line <br /> FILTER BED ❑ Distance to nearest: Well Foundation _�— p y <br /> Size Number <br /> SEEPAGE PITS JI Depth Property Line <br /> SUMPS <br /> LI Distance to nearest: Well Foundation�— <br /> DISPOSAL PONDS <br /> I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an <br /> ` rules and regulations of the San Joaquin County work for <br /> Home owner or tic n�agent's rsigner torbecome certifies the <br /> ecI to following: <br /> kman'srtcompensation lawsoof California."Contractor's lhiri g <br /> othis r sub contracting signature <br /> Home <br /> amp oy Y person <br /> certifies the following: u certify that s the peRormance of the work for which this permit is issued,l shall employ persons subject to workman's compensa- <br /> Thelaws of California." <br /> The applicant mus call for all required inspeetiona. Complete drawing on reverse side. e <br /> Tide: r Date: 1 <br /> Signed X r <br /> FOR DEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted by ++ t <br /> on by Date <br /> Pit or Grout Inspection by Date <br /> 1 f�Final Inspecti <br /> Additional Comments: 1 <br /> r Public Health <br /> Applicant �- Return all copies to: Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> [ CK PERMIT NO. <br /> ffFEECAbyTETAMNT DEEAMOUNT REMITTED <br /> .� <br /> + EN 13-24 IREV.t I n a] <br /> EH,1.26 <br />