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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Pe <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> %V/ P 0 BOX 2009, STOCKTON, CA 95201 <br /> EXPIRES 1 YEAR FROM )A E TS�rr�n <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. QQ p� <br /> Job Address �j� �7r ?3a� 6 <br /> City-r-�-,�— Lot Size/Acreage <br /> Owner's Name <br /> L Address _�5��,` <br /> A _ Phone <br /> ContractorL" Address <br /> TYPE OF WELL/PUMP: License N� � Phone <br /> NEW WELL O WELL REPLACEMENT <br /> PUMP INSTALLATION p DESTRUCTION O Out of Service Well O <br /> DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR', OTHER O Monitoring Well <br /> SEWER LINES <br /> ---- DISPOSAL FLD. PROP. LINE <br /> FOUNDATION <br /> --__ AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS PITS/SUMPS <br /> n Industrial O Open Bottom O Manteca Dia. of Well Excavation <br /> 1:1 Domestic/Private O Gravel Pack Dia. of Well Casing O <br /> I`l Public O Tracy Type of Casing. <br /> (1 Other (-1 Delta Specifications <br /> Irrigation Depth of Grout Seal <br /> �. Approx. Depth I,astern Type of Grout <br /> Repair Work Done Surface Seal Installed by <br /> Type of Pump 6A Q <br /> Well Destruction H.P. �� State Work Do <br /> Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is (y) <br /> ___ Commercial __ Other <br /> Installation will serve: Residence available within 200 feet.) ` <br /> ______ <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK O Type/Mfg Water table depth <br /> PKG. TREATMENT PLT. O Capacity__________i No. Compartments <br /> Distance to nearest: WellMethod of Disposal <br /> Foundation—__ property Line <br /> LEACHING LINE Cl No. 8 Length of lines <br /> FILTER BEDCJ Distance to nearest: Well Total length/size <br /> Foundation___•_____ property Line <br /> SEEPAGE PITS 11 Depth <br /> SUMPS Size Number <br /> Cl Distance to nearest: Well <br /> Foundation______ property Line <br /> DISPOSAL PONDS p <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin count --dirt <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: V ordinances, state laws, and <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 /> the performance of the work for which this permit is issued, I shall not <br /> certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall employ <br /> tion laws of California." p y persons subject to workman's comp nsa <br /> The app' st call for all re fired inspe ons. Complete drawing on v e side. <br /> Signed <br /> s <br /> Title: <br /> Date: <br /> F DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date � Z Area <br /> Pit or Grout Inspection by <br /> Date Final Inspection by � � �{ <br /> Additional Comments: Date <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 <br /> INFO AMOAMOUNT REMITTED CK <br /> /�� <br /> + EH 13.211REV.iinsi L CASH RECEIVED BY DATE PERMIT'NO. <br /> EH 14•29 f� ��`� <br /> .rl. , 1-Ia,q <br />