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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 0 BOX 2009, STOC%TON, CA 95201 <br /> EMITEXPIRES 1 YEAR- FROM DATE ISSUED <br /> (Complete in Triplicate) u <br /> Application is hereby made�.to San Joaquin County for a permit to construct and/or install the work herein described. This II <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 /> Job AddressC'V'� 1!" City Lot Size/Acreage j <br /> Q <br /> 118 t� _g Phone <br /> Owner's Name Address 2 �! <br /> Contractor Address _License No.,xj��� Phonet�ltJ/�0 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well C] <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR Cl OTHER ❑ Monitoring Well <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 /> Dia. of Well Excavation Dia. a#Well Casing <br /> n%Industrial C1 Open Bottom 13 Manteca <br /> (:1 Domestic/Private ❑ Gravel Pack n Tracy Type of Casing Specifications r <br /> a <br /> C1 Public [I Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —.Approx. Depth t I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth _ <br /> Depth Filler Material & Depth <br /> "TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION i I DESTRUCTION l I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Y Commercial 5 cher <br /> Number of living units: __L Number of bedrooms 1 <br /> Character of sail to a depth of 3 feet: Water cable depth <br /> SEPTIC TANK. L§—Type/Mfg Capacity ;�6%' No. Compartments <br /> PKG. TREATMENT PLT:-CI Method of Disposal <br /> � � y ' <br /> Distance to nearest: Well Foundation / Property Line _ <br /> LEACHING LINE 9i�No.'4 Length;of lines ! Total length/size a a <br /> FILTER SED C! Distance to nearest: Well � Foundation c.2Q Property Line. <br /> SEEPAGE PITS 1+4-Depth' f -SizeNumber. <br /> SUMPS f, LI Distance to nearest: Well AKAS-tl Foundation Property Line <br /> DISPOSAL PONDS ID <br /> I hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin.County c A. <br /> Home owner or licensed agent's signature certifi6s the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> f employ any person in such manner as to7become 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 taws of California." <br /> The app' ant must call for all regilifeo inspections, Complete dfawing on reverse side. <br /> Signed Title: /I/CG�/�C�' ____ Date: v _ <br /> FOR DEPARTMENT USE ONLY e <br />' Application Accepted by Date Area / y <br /> r <br /> Pit r Grout Inspection by Dat /Final Inspection b}r �r��ct�` -- Date✓ Lf <br /> fry. <br /> dditional Comments:-.- <br /> Applicant - Return all copies to: San Joaquin.County Public Health t� <br /> Services, Envirotimental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> I[ <br /> INFO <br /> CA/SH <br /> 5 + EH 13.24 IREV.rinse <br /> EH 21.25 <br />