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APPLICATION FOR PERMIT <br /> 5 <br /> t <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1.601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> EXPIRES 1 YEAR FROM DATE ISSUED <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 /> i <br /> Job Address <br /> C' city Lot Size/Acreage <br /> Owner's Name SIZZ ZZZsio^l Address Phone <br /> Contractor A 6Z46_--e_Address ' License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT) 0 DESTRUCTION Cl out of Service Well ❑ <br /> PUMP INSTALLATION 13SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL___ PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> i 1 Industrial ❑ Open Bottom 0.Manteca Dia. of Well Excavation Dia. of Well Casing �fJ <br /> C] Domestic/Private Ci Gravel Pack ❑ Tracy Type of Casing Specifications <br /> i'1 Public P Cl Other rl Delta Depth of Grout Seal Type of Grout <br /> E I Irrigatiori —.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well'Diameter' Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIRlADDITIONP< DESTRUCTION I I Wo septic system permitted if public sewer is <br /> available within 200 feet.) , <br /> Installation will serve: Residence`/Commerciat— Other <br /> r ;. <br /> Number of living units: — Number a� bedrooms 3 <br /> Character of soil to a depth of 3 feed"=' Water table depth <br /> SEPTIC TANK ❑ TypelMfgCapacity No. Compartments <br /> PKG. TREATMENT PITT. ❑' Method of Disposal <br /> 0 <br /> Distance to nearest: well Foundation Property Line �6 <br /> l <br /> LEACHING LINE Ll�> No. & Length of lines Total length/size <br /> FILTER BED Distance to nearest: Well Foundation 46 Property Line <br /> i <br /> SEEPAGE PITS>, I I Depth Size Number <br /> SUMPS 0 Distance to nearest: Well _Foundation Property Line <br /> DISPOSAL.PONDS ❑ <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, and <br /> rules and regulations of the San Joaquin County <br /> I� Home owner or licensed agent's Sioature 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 sub-contracting 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." ! + <br /> The applicant must call for''It requi d inspections. Complete drawing on revgfse side. <br /> Signed X 1146r- Title: —,o Date: _ 7z-�7 ''• <br /> ZFO P T NT USE ONLY <br /> Application Accepted by d� Date <br /> Area <br /> Pit or Grout Inspection by y Date Final inspection by "Date <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 /> PEE AMOUNT DUE` AMOUNT REMITTED GASH RECEIVED 9Y DATE PERMIT'NO. <br /> INFO <br /> . <br /> EH 13.24 1f1EV,I/e 55 ' <br /> r EH 1429 <br />