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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 /> PER_ 1tlIT EXPIRES 1 YEAR FROM DATE SSUEIED <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 Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public ffealth Services. 3 <br /> v� Lot Size/Acreage <br /> �C.4 City <br /> Job Address <br /> Owner's Name �� Address S f 'Q! Phone u <br /> f� -7 1 8�7 _ <br /> Contractor —L "3f"� fr'Address~~~' License No.�_� Phone { <br /> TYPE OF WELL/PUMP' NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ <br /> i OTHER ❑ Monitoring well [3 <br /> PUMP iINSTALLATION EISYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE t TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> {.I <br /> Dia. of Well Casing <br /> Industrial }. ❑ Open Bottom <br /> ❑ Manteca Dia. of Well Excavation <br /> Type of CasingSpecifications ` <br /> Cl Domestic/Private x 13Gravel Pack C] Tracy {� <br /> Type of Grout <br /> I'I Public i El Other Ll Delta Depth of Grout Seal r <br /> i I Irrigation Approx. Depth I I Eastern Surface Seal Installed by <br /> H P 5 State Work Done <br /> Repair Work Done C7 Type of Pump ' Sealing Material & Depth <br /> Well Destruction ;.❑ �Well Diameter <br /> . Depth <br /> : Depth: <br /> Filler Material <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIRlADDITION DESTRUCTION I I.I Noavave ble system permitted if public sewer is <br /> • / ailaable within 200 feet.l <br /> installation will se'rve:t.-Residence",--Commercial '"Other- <br /> Number <br /> therNumber of living uniti: Number of bedrooms 3 <br /> . <br /> 'Character of soil to a,depth of,3 feet: u _ Water table depth <br /> III / r_. �,. . ..,, .�� ,,_ ._. <br /> SEPTIC TANK. li; Type/Mfg �- °TM w Capacity — No. Compartments <br /> PKG. TREATMENT PLT-. ❑ t ti i --� 1 }} ?�r" Method o Dispopal <br /> Distance to-nesrest: Foundation I t3 Property Line <br /> LEACHING LINE &­--No.- of,lines. Total length/size <br /> q1 <br /> FILTER BED r a LI .Distande'tc-nearest: t Well Foundation Property Line <br /> SEEPAGE PITS 11 depth '�5 Number <br /> SUMPS '. LIQ Distance to nearest:_ - Well- Foundation Property Line <br /> DISPOSAL PONDS <br /> M1f i hereby certify that I have prepared this application and thatifie work will be done_ in acc_afdan_ce with'San Joaquin county ordinancjs, state laws, and <br /> rules and regulations of the San Joaquin County; shall <br /> Home owner or licensed agent's signature certifies the following:.-"I certify that in the performance of the wok-fq�which this r subpermit is issued, I signature not <br /> employ any person-in.such.manhaej as to become subject to workman's compensation laws of California." Contractor's hiring or sub contracting signature <br /> certifies the following: "I certifythat in tha'performance of the work for which this-permit is_issued, I shall-employ persons subject,to wisikman's compensa <br /> tion laws of California." - <br /> The applicant must call for all r fired inspections. Complete drawing on reverse <br /> side. r <br /> r Title: r 19 _1 V ..' Date:-� . 1 5� r C f <br /> ` <br /> Signed X ;. . <br /> FOR DEPARTMENT USE ONLY ' <br /> l ?� <br /> Application Accepted by Area <br /> Date. -- -- - <br /> Pit or Grout Inspection by Date Final Inspection byDate, <br /> Additions! Comments: <br /> Applicant - Return a.0 copies to: San Joaquin_County;Public Health_ _ , - 1. <br /> - -� Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CA8N _ RECEIVED.BY DATE. r PERM17'N0. . <br /> _ _ _ INFO.,.- <br /> 7 f q P f <br /> EH 13-241REV.+in 5l <tVC/ - - — 9"Y� r".I '"[ � <br /> r EH 21.20 ! <br />