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j. <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON-,- CA 95201 <br /> R. <br /> PMIT EXPIRES 1 YEAR FRO - DAT $ JU <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 /> i application is made in compliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> 4 / <br /> Job Address City_ �/CSA)Lot Size/Acreage <br /> o'wner's Name41�44,gLy, '! Address - Phone <br /> I Contractor �+ 1% YlJi _-Address License Ntx hone <br /> �. TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑� OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES , DISPOSAL FLD. PROP" LINE <br /> FOUNDATION AGRICULTURE WELL --OTHER WELL PITS/SUMPS <br /> I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> F1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of.Well Casing <br /> D Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications <br /> f I'1 Public D Other f 1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth' <br /> Depth, Filler Material 8 Depth <br /> TYPE OF SEPTIC WORK:, NEW'INSTALLATiON REPAIR'/ADDITION'( I " OESTRUCTION`I'I [Nonseptic system permitted if public sewer is <br /> av fable within 200 feet.l <br /> Installation will-serve: Residence Commercial_ Other <br /> Number of living units:' Number of bedrooms _ ,s �• ' . <br /> Character of soil to a depth of 3 feet: Water table-depth <br /> SEPTIC TANK 0 Type/Mfg Capacity .No. Compartments <br /> PKG. TREATMENT PLT. ❑ �pr9/t'Lu�J f y-- r Method o.f Disposal <br /> Distance to nearest: Well w Foundations -'Property Line--.�- <br /> LEACHING LINE No. & Length of lines Total length/sire r <br /> rr FILTER BED ❑ Distance to nearest. Well Foundation Property line <br /> SEEPAGE PITS X Depthi ' <br /> r �]___ Size J Number ~ <br /> SUMPS . LI 401stanra-to'nearest:-Y Well Foundation ` Property.Line <br /> DISPOSAL PONDS ❑ S . .d1 t r te `' kms: rX <br /> I. I hereby certify that I have prepared this application and that the work will be done in'accordance withan 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 Ctilifornia." 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 applicant must call for equir d inspections. Complete drawing on reverse side. <br /> Signed XTitle: Date: > <br /> I - FOR DEPARTMENT USE ONLY <br /> Application Accepted by r. Date Area <br /> I <br /> � Pit or Grout Inspection by Date .Final Inspection by _ Date <br /> Additional Comments: ` <br /> Applicant - Return all copies to: '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 b AMOUNT REMITTED RECEIVED BY BATE PERMIT'NO. <br /> INFO r _ <br /> . EN 17-24 IREV.1/'16) <br /> EH 74.26 s D <br />