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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 PHONE <br /> p•0 BOR 2009`,VSTOCKTON, CA09)4695201_5�20 y, <br /> I <br /> F,gp RES 1 YEAR FROM DA E <br /> (Complete in Triplicate) <br /> in <br /> Application is hereby made to San Joaquin County for a permit to construct and/or <br /> ol862stall <br /> and theeRules an dwork eRegulations dof Sane <br /> application is made in compliance with San Joaquin County Ordinance No. 5 9 <br /> Joaquin county Public Health Services. <br /> WNi City Lot size/Acreage <br /> Job Address <br /> Phone <br /> Address <br /> Owner's Name <br /> 10 <br /> Contractor Address. <br /> License No, ����� Phone <br /> NEW WELL ❑ ervice well 0 <br /> WELL REPLACEMENT ❑ DESTRUCTION ❑ a't Monof itoring Well Ll <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR 0 OTHER ❑ <br /> PUMP INSTALLATION ❑ <br /> SEWER LINES J DISPOSAL FLD. PROP. <br /> LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL PITSISUMPS <br /> FOUNDATION ___ AGRICULTURE WELL - <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> C7 Industrial ❑ Open Bottom © Manteca Dia. of Well Excavation <br /> Type of Casing Specifications <br /> [_} Domestic/Private M '" '❑ Grave! Pack ❑ Tracy Depth of Grout Seal Type of Grout [� <br /> 1'1 Public [I Other n Delta )(v� <br /> ' I I irrigation —Approx. Depth I 1 Eastern Surface Seal installed by <br /> Type o1 Pump H.P. State Work Done <br /> Repair Work Done Sealing Material & Depth <br /> i Well Destruction ❑ Well Diameter Filler Material & Depth <br /> f Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITIO; DESTRUCTION I I availableSeptic <br /> w hin 200 teetpermitted if public sewer is <br /> installation will serve: Residence�!t CommercialOther <br /> Number of living units: -4- .Number of bedroorps Water table dl'P'hq,, <br /> ` Character of soil to a depth of 3 feet: - - No. Compart <br /> E SEPTIC TANK *6 Type/Mfg Capacity - <br /> r" ff Method of Di <br /> PKG. TREATMENT PLT.❑ i <br /> Distance to nearest: Well - Foundation Property Line <br /> LEACHING LINE ft4-No. & Length of lines <br /> r E / Total length/size <br /> jar_ Foundation r Property Line FILTER BEDC] Distance to nearest: Well <br /> 1 <br /> SEEPAGE PITS IA- Depth �~ Sire% - Number r <br /> SUMPS LI Distance to nearest:,-_ Well Foundation <br /> Property Line <br /> DISPOSAL PONDS D - <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 f' <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 she 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 inrthe.pertormance of the.work for which this permit is issued, I shall employ parsons subject to workman's compensa- <br /> tion laws of California." r i <br /> i The applicant mufni all r it d inspections. Complete drawing on reverse side. <br /> -Titla: -__ e�f un 7� -T= <br /> Date:- <br /> Signed <br /> FO DEPARTMENT USE ONLY <br /> i <br /> - Date �� �� Area <br /> yAdpdi�finitjcation Accepted by ZrGrutInspection byate Final Inspection by Date?oComments: <br /> Applicant Return all copies to: San <br /> rvi�uiEnvi onmeounty nttaliHealthtPermit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> CK RECEIVED BY DATE PERMIT'N0. <br /> I fEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO yg <br /> tEH13-24{rIEV.1/n51 - y <br /> I-Attt,t' � OBJ <br /> I EH'44.29 <br /> t <br />