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a 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 /> 1ERMIT EXPIRES 1 YEAR FROY_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 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health.Servilce/s.. <br /> Job Address Cizy�1600 Lot Size/Acreage Klea <br /> Owner's Name So N Address SAwl Phone rL <br /> Contractor^ lloae'^ Address � License Na. `f hone 7 O � <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 11 OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL!�_L. -- PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO_NS\k <br /> n Industrial T ET Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Prijate ,CfGravel'Pa;ck-^ °fir„/ ❑ Tracy �rTipe b'f"CasinSpecifications <br /> I'1 Public 1-1 Other w F1 Delta , Depth,of Grout Seal Type of Grout <br /> I # Irrigation .�" ,,Approx. Depth 0 1 Eastern p , S.uriace Seal Installed by- <br /> Repair Work Done ❑ Type of Pump�`" " - H.P` - `.,State Work Done_ <br /> Well Destruction ❑ Well Diameter "; Sealing lI aterial & Depth' <br /> Depth .;:.,Fill'er Material 8 Depth , <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIRIADDITION l DESTRUCTION I I (No septic system'permitted if public sewer is , <br /> available within 2W'feet.) <br /> Installation will serve: Residence X1, Commercial_ Other` <br /> Number�of living units: —4- Number ofbedrooms ,-' <br /> Character of soil to a depth of 3 feet: 4.�it]f9 � '' Water table depth r7 +� <br /> SEPTIC TANK. ❑ Type?Mfg * '-----`- Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ ,i Method of Disposal <br /> Distance'to nearest: Well Foundation '' Property Line <br /> LEACHING LINE Ll No. & Leng-th of lines " L36=13 1hlO Total length/size <br /> FILTER BED 0Distance to nearest: Well�� Foundation '� Property Line <br /> SEEPAGE PITS 11 Depth Size Number J <br /> SUMPS 0 Distance to nearest., Well Foundation Property Line <br /> DISPOSAL PONDS ❑ s <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 regulation's ofthe Sari Joaquin .t3ounty ; <br /> Home owner or licensed agent's signature cenifies the following: "I certify that in the performance of the work for which this permit is issued, I shalt 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 its issued,,I shall employ persons-subject to workman's Compensa- I <br /> tion laws of California." <br />[ The applicant must call for aH re uired inspe tions. Complete drawing on reverse side. <br /> Signed XTitle: <br /> 1 FOR DEPARTMENT USE ONLY <br /> Application Accepted by - Date !- ' : Area 13 <br /> Pit or Grout Inspection by Date Final Inspection Date <br /> Additional Comments: <br /> Applicant - Return all copiee to::Sen Joaquin-Copnty,Public Health - <br /> J, Services, Environmental Health Permit)Servicea <br /> .�•�"T601 E:�Hazelton Avee. P 0 Bax 2609;Stoikion,YCA +95201 <br /> r <br /> EEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO y� �}%� CASH <br /> . EH 13-21IREV.I/K5) rJ t.00 <br /> EHA,26 jI Hi`.'" 1235-0 <br /> r 1i <br />