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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> I ENVIRONMENTAL HEALTH DIVISION r <br /> 1601 E. HAZELTON AVE. , PHONE (209)4683420 _ <br /> P O BOX 2009, STtOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 /> J uin County Public Health Services. <br /> Job Address City. C- Lot Size/Acreage �a ._��fes_ <br /> � �tiada` a°� <br /> Owner's Name —�_Q l Address <br /> Phone <br /> 17 <br /> Contractor Address License No. Phone_ <br /> PE OF WELL/PUMP: NEW WELL ElWELL REPLACEMENT,❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION C3 SYSTEM REPAIR ❑ OTHER ❑ Monitoring <br /> Well �� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION, AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL j 'PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L) Industrial ❑ Open Bottom II Manteca .LL Dia. of Well Excavation Dia. of Well Casing\ <br /> Cl Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications <br /> Depth of Grout Seal Type of Grout <br /> F1 Public (.1 Other 6 Delta <br /> i I Irrigation —.Approx.lDepth I ) Eastern Surface Seal Installed by. <br /> Repair Work Done 0 Type of Pump H.P. �' State Work Done <br /> r " q <br /> Well Destruction ❑ Well Diameter <br /> Sealing Material & Depth <br /> Depth r Filler Material b Depth <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION X REPAIR/ADDITION I I DESTRUCTION { .I (No seplicr'system permitted if public sewer is - <br /> T available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Others - ' <br /> Number of living units:=` Number of bedrooms <br /> ,ate <br /> Character of soil to a depth of 3 feet: m '°"r°���r-�-Water table depth. <br /> SEPTIC TANK. Type/Mfg "'P�-.t Capacity 0. Compartments r <br /> PKG. TREATMENT PLT. ^^ ' . ,,..��- � y � .r �' Method ol Disposal <br /> Distance to nearest: Weq, _ Foundation Property Line—'I` <br /> 4 <br /> LEACHING LINE SA No. & Length of lines Total length/size - <br /> FILTER BED Ci Distance to nearest: Well F6undation Property Line <br /> SEEPAGE PITS 1 ) Depth Size _ _ Number <br /> SUMPS L) Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ , <br /> I hereby certify that I have prepared this application and that the work will be done in accufdance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> 1 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." r r . �_ k <br /> The applic nt ust call for all re fired inspections. Complete drawing on reverse side_, x} <br /> x Signed T•iNe: - '•• �" -Osie: , <br /> FOR DEPAR MENT U5 ONLY �_ <br /> 3 a ' <br /> r Application Accepted by44 M Date Area <br /> Pit or grout Inspection by Date Final Inspection by a-/ Date G D <br /> .r <br /> 2 <br /> Additional Comments: - - - <br /> ° Applicant - Return s11 copies to-m San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMITmNO. <br /> INFO _ <br /> f J� 7 <br /> + EH 13-21 tREV.I/M!5) _ yr <br /> EH i1.26 <br /> l C9 0 0 'D go"' <br />