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APPLICATION FOR PERMIT , iy`A r <br /> N <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES- � �.� <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 FEB z 6 1991 <br /> P O BOX 2009, STOCKTON, CA 95201 EN VIRONNIENTAL HEALTH <br /> PERMIT EXPIRES 1 YEAR FROM DATE ED iE�/ f :, :i <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 /> Job Address An&f 066City Lot Size/Acreage <br /> i. Owner's Name I Address -� Lrl �K - Phone _ 1' <br /> t <br /> Contractor LA"_ Address License No. -=x Phone <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 FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS l <br /> E Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing 6" <br /> �Q <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 7,O` <br /> l"1 Public Cl Other I I�Delta_ _T Depth oI.Grout 5riai Type of Grout ° lJ� <br /> I I i Irrigation —.Approx..Depth I I Eastern TSurface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. t-lam" State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth ' <br /> Depth t r riller,Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRlADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is <br /> J [ available within 200 feet.] n <br /> Installation will serve: Residence T Commercial Other <br /> Number of living units: Number of bedrooms + ' <br /> Character of soil to a depth of 3 feet.. I Water table depth <br /> SEPTIC TANK ❑ Type/Mfg'F - W Capacity No. Compartments <br /> PKG. TREATMENT PET. ❑ + j Method of Disposal <br /> Distance to nearest: , WeII' `""^ -��—.Foundation w. Property Line �* <br /> LEACHING LINE ❑ No. & Length of lines ,Total length/size <br /> FILTER BED CI Distance to nearest: Well Foundation ; Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS LI Distance to nearest�: '.Wel! Foundation Property Line <br /> - <br /> DISPOSAL PONDS ❑ � <br /> 1 hereby_certify_that t_have..prepared-this,application-and.xhat.the_work-will-be-done-in-accordance••with San-Joaquin-county-6rdinances, state laws, and <br /> rules and regulations of the San JoaquiA county <br /> Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> certifies the foil, ng: '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 Calif mia " <br /> The applica mu call for all requif nsp ct o Complete drawing on revere <br /> Signed X Title: ADate: Q! �Qa::q� <br /> I FOR EPARTMENT USE ONLY 1 <br /> ' Application Accepted by DateArea 1 <br /> CJ <br /> � �c--� <br /> Pit or Grout Inspection by Date Final Inspection by—L W L —�> Dated—� <br /> Additional Comments: <br /> Applicant — Return all copies. to: , San Joaquin County Public Health <br /> 4 Services, Lnvironmental Health Permit/Services <br /> ,e-1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201FEE <br /> i <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-244REV.1/8 SI <br />