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1 j <br /> I APPLICATION FOR PERMIT <br /> f <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> k 1601 E. HAZELTON AVE. , PHONE (209)468--3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> I <br /> 4 PPEMIT EXPIRES 1 YEAR FROM DATE ISSUED. <br /> (Complete in Triplicate) <br /> I 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. 51+9 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. I <br /> Job Address a26120;Z City ` Lot Size/Acreage <br /> Owner's Name Address A- Phone <br /> Contractors Address L�= License too. �, Phoned,6`'`v-0 <br /> k <br /> L TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> r + PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> f7 Domestic/Private ❑ Gravel Pack n Tracy Type of Casing Specifications <br /> I'1 Public (D-Other F1 Delta Depth of Grout Seal Type of Grout I ' <br /> I I I Irrigation �.Approx. Depth I I Eastern Surface Sedi installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done T <br /> Well Destruction ❑ Well Diameter Sealing Material &,Depth <br /> 111E Depth Filler Material b Depth t t <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION tLeREPAIR/ADDITION I I DESTRUCTION i I (No septic system petmitted it public sewer is <br /> available within 200 feet.I I <br /> Installation will serve: Residence Z Commercial— Other �"" ^ '""'°'• ` <br /> P Number of living units: Number of b d orris _ _ d <br /> Character of soil to a depth of 3 feet: C3�r., `J '} _Water table depth <br /> 1° SEPTIC TANK �r_Type/Mfg Capacity No, Compartments 2- <br /> PKG. <br /> PKG, TREATMENT PLT,❑ Method of Disposal <br /> O da +�_ r J <br /> Distance to nearest: W%ell Foundation Propeny Line <br /> LEACHING LINE LWINo. & Length of lines _�� '" V0 `` Total length/size-- <br /> FILTER <br /> ength/size FILTER BED ❑ Distance to nearest: Well /,,, ` - - fes` <br /> _(2✓ Foundation `�©T Property Line <br /> h. <br /> SEEPAGE PITS 10/'Depth ;' Size . - - . �5 E� Number <br /> SUMPS LI bstan4 to'nearest: Well r3 Foundations Property Line <br /> DISPOSAL PONDS ❑ <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 apph tst call for all r Oro insPections. Complete drawing on reverse side. <br /> i <br /> Signed 7�1.. Title: _����'��- -_- Data: �I <br /> FOR DEPARTMENT USE ONLY <br /> lication Accepted by ' !` Date ^Z t Area <br /> it or rout inspection bq _� Date Z`Z Z Final Inspection by!�)�,, Date 2 Z ✓j <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 INFO AMOUNT DUE AMOUNT <br /> 1114 <br /> % AMOUNT REMITTED CASH r RECEIVED BY DATE PERMIT IVO. <br /> . EH 1324IREV.Iixst `: L4 a`-' T r p' '� L l `O('1 <br /> EH 94.26 <br />