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i' APPLICATION FOR PERMIT <br /> h <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> f � � a <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E, HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PBUIT EXPIRES 1 YEAR FROM DATE .SSUED <br /> (Complete in Triplicate) <br /> { <br /> Application is her made to San Joaquin County for a permit to construct and/or install the cork herein described. This <br /> application is made in co>aplience With San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> I Joaquin County Public Health Services. , <br />!r ` L� 1J Lot Size/Acreage �au-55 <br /> �7 <br /> Job Address `� ` City <br /> r's Name <br /> Address �� S <br /> O 4 �� Phone <br /> Owne <br /> Contractor Address License No, Phone <br /> TYPE OF WELL/PUMP: I`, NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well' 0 <br /> PUMP INSTALLATION ElSYSTEM REPAIR C) OTHER 13Monitoring Well C7 <br /> _. <br /> +$ DISTANCE TO NE=AREST:-SEPTIC TANK- �-- _SEWER CINES. _1 � DISPOSAL FLD. PROP. LINE <br /> FO,UNDATION_ ..AGRiCULTURE WELL_ OTHER.WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> lS cifications <br /> C.l Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing pe <br /> FI Public i-1 Other fl Delta Depth of Grout Seal Type of Grout <br /> -- <br /> I I Irrigation .Approx. Depth t I Eastern Surface Seal Installed by <br /> _ - <br /> Repair Work Done ❑ Type of PumpH.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth - <br /> '": Filler Material & Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRlADDITION I I DESTRUCTION I I Wo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Y_ Commercial_ Other ' <br /> Number of living units: L Number of b drooms <br /> Character of soil to a depthlof 3 feet: Water table depth 76 <br /> SEPTIC TANK ,Type/Mfg oc Capacity_—No.-Compartments <br /> I <br /> J 'PKG. TREATMENT PLT. ❑ �. ��r, � f Method of Dispoyal <br /> li (Distance to nearest: Well Foundation Property Line ( 160 <br /> ' JIB <br /> 'LEACHING LINE >t ]No. & Length of lines Total length/size <br /> +, FILTER BED [3 (Distance to nearest: Well Foundation C 0 .Property-Line / µ <br /> I �-5 Size a Number <br /> SEEPAGE P,l\TS ' <br /> � Depth <br /> SUMPS Ll :bistance to nearest: Well 1-501 Foundation Property Line <br /> DISPOSAL PONDS © I� <br /> 1 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 /> > krules 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 became subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signaturecertifies 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.' i� <br /> The applicant must call for allh► aired in pections. Complete drawing on reverse side. <br /> Signed Title: Date: <br /> Ip F RTMEN7 USE ONLY <br /> Application Accepted by Date ,_.. <br /> —oc�o` I�_ Area r <br /> r � <br /> or Grout Inspection by Date( Final Inspection by Datt� <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 AM0"UNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PEftMiT'Nq. <br /> i kNFO CASH <br /> . EH 13-24(REV.t/H5) F-7]7,p-b 5 V-? a_011 0 10—/ <br /> PT� <br /> EH 14.20 vV <br /> I� <br />