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j APPLICATION FOR PERMIT E S <br /> M <br /> l - SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> �\ t <br /> • /�! ENVIRONMENTAL HEALTH DIVISION �� W <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> NJk1 <br /> a �•�r <br /> P-MIT _EXPIRES 1, YEAR FROM DATE ISSUED �t <br /> (Complete in Triplicate) 04 <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the cork herein described. This <br /> application is made incompliance 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 <br /> City Lot Lot Size/Acreage <br /> I Owner's Name_-1. i'� ,�y � Address Phone <br /> 6 fJ <br /> Contractor Address_ t `�' `a ---C License No. (�?phone 2;t <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK; SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS , <br /> r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ff Manteca Dia. of We1'Excavation Dia. of Well Casing <br /> C7 Domestic/Private LI Gravel Pack r L7 Tracy Type of Casing Specifications <br /> If i'I Public Cl Other ' n Delta Depth of Grout Seal <br /> Type of Grout <br /> I I Irrigation _ Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Materier'&'Depth;"`--' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION <br /> (No septic system permitted it public sewer is ^� <br /> vailable within 200 feet.l <br /> installation will serve: Residence Commercial T,—„ Other- � M <br /> Number of living units: Number of bedrooms v1� <br /> Character of sail to a depth of 3 feet: 'It *• ;, <br /> SEPTIC TANK. Witer-tatile depth <br /> ❑. Type/Mfg Capacity r ..,,•.,No• Compartments � <br /> PKG. TREATMENT PLT. ❑ a <br /> i r <br /> Distance to nearest: Method of Disposal <br /> Well Foundation Property Line <br /> C I <br /> LEACkNG LINE ❑S No. & Length of lines <br /> Total length/size <br /> FILTER BED ❑ Distance to nearest: Well + <br /> Foundation Property Line �k d <br /> SEEPAGE PITS 11 Depth Size t �� <br /> _ Number <br /> SUMPS LI Distance to nearest: Well Foundation <br /> 'Property Line Q <br /> DISPOSAL PONDS ❑ i <br /> I hereby certify that I have prepirad this application and that the work will be done in accordance with San Joaquin county ordinances, state la s, and <br /> rules and regulations of the Sari"Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "I certify that i the performance of the work for whichthis permit is issued,'l shall not t <br /> employ any person in such mann`sr as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I s6a employ.pe_rsons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all r aired ins ` ,I t <br /> q inspections. COmpjete drawing on revers§side. r <br /> Signed P, <br /> Title: Date: <br /> FO D NT USE ONLY <br /> Application Accepted by <br /> _... ,Date. c7 --Area- <br /> Pit or Grout Inspection by4l <br /> Pate Final Inspection by t <br /> ^ ' Date <br /> Additional Comments: L CIC wIA� <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, LPtaviroamental Health Permit/Services <br /> 1601 E. Hazelton Ave., P ox 2009, Stockton, CA 95201 �\ <br /> FE AMOUNT DUE AMOUNT REMITTED <br /> CASH RECEIVED BY DATE PERMIT'NO. <br /> . EK 13-21 fREV.tiHSl �1���� ,� S^�v7� r'r - 5 3�_I� <br /> E47 .26 �[(/ V t!/_r 1 <br />