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APPLICATION FOR PERMIT <br /> P <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 <br /> l P O BOX 2009, STOCKTON, CA 95201 <br /> EXPIRES 1 YEAR ERON DATE ED <br /> 1' (Complete in Triplicate) <br /> Application is hereby m-de,to San Joaquin County for a permit to construct and/or install the wont 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. <br /> //r 0 Cityf�l��'E — Lot Size/Acreage <br /> i Job Address p� n <br /> ' J� /c7i!1j G/ _ Phone b <br /> � owner's NarnRo' �B �-� Address - <br /> Contraclor Address License No. <br /> Phone <br /> TYPE OF. ELL/PUMP: NEW WELL ❑ WELL RE EMENT ❑ DESTRUCTION ❑ Out of Service Well Cl <br /> PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER O <br /> Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SE tES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGR` L OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PRO13LFM AUCTION SPECIFICATIONS <br /> Cl Industrial © Open Bottom D MantecaWell Excavation Dia. of Well Casing <br /> Domestic/Private 0 Gravel Pack L7 TracyCasing SpecificationsI'1 Public l-1 Other f-1 Deltaf Grout Seal Type of Grout L <br /> � V <br /> I I Irrigation Approx. Depth l I Easte SuHace Seal installed by Q <br /> Repair Work Done C7 Type of Pump H.P. \', State Work Done— Q <br /> Well Destruction O Well Diameter , Sealing Material & Depth <br /> F Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l I DESTRUCTION I I lNo septic system permitted if public sewer is <br /> available within 2DO feet.) <br /> Installation will serve: .Re idence 4�Commercial_ Other <br /> Number of living units: Number of edroo / <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. © Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ j Method of OispoSai <br /> ` Distance to nearest: Weil Foundation 97) Property Line <br /> II <br /> LEACHING LINE C) No. & Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> lf VN <br /> SEEPAGE PITS 1 ) Depth _ /a -Size Number <br /> SUMPS Ll , Distance to nearest: Well1 `1 d' Foundation S� f 'Property Line -� <br /> DISPOSAL PONDS O W <br /> l <br /> i 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, an <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, 1 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 taws of Californ <br /> l The applicant st call r all requir d% spec omplate drawing on reverse side. <br /> Signed Title: <br /> Date: L v <br /> R D ENT USE ONLY <br /> I / w Date Area <br /> Application Accepted by n <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 AMOUNT REMITTED C K H RECEIVED BY DATE PERM17'N0. <br /> INFO --7 H J ' <br /> r ♦ EH 13-24{REV.I/AW / f�,7 ( 6-!(�-`g e) <br /> EH 14.25 0 <br />