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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PE-MIT EXPIRES 1 YEAR FROM DATE <br /> (Complete in Triplicate) <br /> This <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. <br /> application is made in compliance vith San Joaquin County ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> !14A16-H - City Lot Size/Acreage <br /> Lobss <br /> G,DR6 8.L Go.e i 6 -6 7•�'� <br /> a/'JJ� � ���t/CH �t P �A Phone <br /> ame ddress Address License No. �--Phoner ���- ;WELL/PUMP: i�, NEW WELL © WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well L] <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> OTHER © MonitoringNell <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> PITSlSUMPS �. <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> n Industrial ❑ Open Bottom Cl Manteca Dia. of Well Excavation Specifications <br /> CI Domestic/Private Cl Glravel Pack ❑ Tracy Type of Casing <br /> i'l Public <br /> I-1 Other n Delta Depth of Grout Seal Type of Grout <br />' <br /> I _IIpf <br /> I Irrigation <br /> IA yrox. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done L7 Typs of Pump H.P. State Work Done <br /> Sealing Material & Depth r <br /> Well Destruction ❑ Well Diameter _. v <br /> Deplh Finer Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I I afvailabesepti <br /> systithinem <br /> rented it public sewer is <br /> installation will serve: Residence— Commercial— Other <br /> Number of living units: 1I: Number of bedrooms <br /> 4 Water table depth � <br /> Character of soil to a depth of 3 feet: � <br /> SEPTIC TANK ❑ Type/Mfg apacity No. Compartments '1 <br /> PKG. TREATMENT PLT. <br /> Ll 11I of Disposal <br /> I <br /> Distance to neare • ell Foundation Property Line <br /> LEACHING LINE I o. & Length of lines <br /> Total length/size <br /> TER BED ❑ Distance to nearest: Wel! Foundation Property Line <br /> II <br /> SEEPA E PITS [ I Depth Size Number <br /> SUMPS Ll `Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS D !I1: v <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, an <br /> rules and regulations of the San Joaquin �ounty <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 subcontracting 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." ,I <br /> The applicant mu call for all required ins ctions. Complete drawing on reverse side. a 9 (� <br /> Signed I• Title: Date: q� <br /> Ii FOR DEPARTMENT USE ONL <br /> Application Accepted by e <br /> Datt 61 Area <br /> f �. <br /> li. Date Final Inspection by Date <br /> Pit or Grout Inspection by <br /> Additional Comments: `-: <br /> l V 444,t <br /> Applicant - Return all copies to: Sen Joaquin County Public Health <br /> �I Services, Environmental Health Permit/Services <br /> I. 1601 E. Hazelton Ave., P D x 2009, Stockton, CA 95201 <br /> f FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> a EH 13•24 lsEv.1/1151 <br /> 1 %0 <br /> EH 14.E <br />