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APPLICATION FOR PERMIT 1"1 EC E I V ESAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 2! <br /> ENVIRONMENTAL HEALTH DIVISION J U L 2 2 tent <br /> 1601 E. HAZELTON AVE. , PHONE (209)46$•-3420 <br /> P O BOR 2009, STOCKTON, CA 95201 ENVIRaNM NTA HEALTH <br /> } R M DA PERM ITf SERVICES <br /> pgmEXP RES 1 YE ft F <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 /> Joaquin county Public Health Services. <br /> \ � Lot Size/Acreage <br /> Job Address City / <br /> Address�� Da Phone <br /> Owner's Name tt <br /> Contractor \t3 r4 Address 3 License lVn. Phone <br /> _ TYPE OF WELL/PUMP: NEW WELL'❑ WELL REPLACEMENT- _ DESTRUCTION ❑ Out of Service Well Ll <br /> "" "� T OTHER ❑ Monitoring well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR <br /> DISTANCE TO NEAREST: SEPTIC TAW- <br /> ` SEWER LINES DISPOSAL FLU. PROP. LINE <br /> FOUNDATION"—`�^ AGRICULTURE'W. ELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROSLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C-} Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> IDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing. Specifications <br /> 71`l Public 1-1 Other ` -- 171 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation t __.Approx, Depth I I Eastern Surface Seat Installed by <br /> -T-'` }�p, ^ State Work Done <br /> Repair Wark Done Q Type of Pump t_ SUS `T— <br /> / Sealing Material & Depth <br /> Well Destruction ❑ Well Diameter (2 _ <br /> ' Filler Material & Depth <br /> Depth <br /> _,TYf_.E 0F,.•SEP_T1C_WS2RK: NEW INSTALLATION_# I _REPAIR&D-OITION-1_1__D.ESTRUCTIONA,l_(No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> i <br /> Installation will serve: 1 Residence— Commercial___ Other <br /> Number of living units Number of bedrooms <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.1D Method of Disposal <br /> j Distance to nearest: Well Foundation Property Line <br /> 1 . <br /> f LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED IC) Distancti to nearest: Well Foundation Property Lina 140 <br /> � r <br /> 1 � <br /> SEEPAGE PITS yfl 1-.Depth '='- - Sire - - Number <br /> SUMPS Cit 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 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: 111 certify that in the performance of the work for which this permit is issued, 1 shall not <br /> t 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 Lertify 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 Ca nia." I ' <br /> The appli call for all req r d inspect o s, Complete drawing on-reversta rside. .- <br /> 117 <br /> Signed X <br /> Title: Date: T <br /> O DEPARTMEN USE ONLY <br /> x r""" <br /> Application Accepted by 1 Date Area <br /> f Pit or Grout Inspection by { Date Final Inspection by 1 Date r <br /> Additional Comments: <br /> r Applicant - Return all copies to: San Joaquin County Public Health : ,�^f�• <br /> Services, Environmental Health Permit/Services ; <br /> 1601 R. Hazelton Ave., P 0 Box 2009, Stockton, 'CA 95201 <br /> -FEE gMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> I .r ICASH <br /> INNFO <br /> . EH 13.241 IREV.t/x 5S <br /> i EH 14,24 r �\ <br />