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APPLICATION FOR PERMIT F <br /> a <br /> :CEIVE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE I <br /> ENVIRONMENTALRE V <br /> PHONE <br /> DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-5`I20 2 19 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> ENVIRONMENTAL <br /> gXP RES 1 YEAR FR AAT PERMIT/SERVICES <br /> (Complete in Triplicate) <br /> J <br /> work <br /> in <br /> Application is hereby glade to San vithuSanCJoaquiaor a County Ordinanceermit to nNoruct 549 ando1862stall and theeRules andeRegulationsdof Scans <br /> application is made in compliance f' <br /> Joaquin County Public Health Services. <br /> of Size/Acreage <br /> Job Address (� <br /> 97 <br /> Phone <br /> ddress <br /> Owner's Nam �` <br /> 1 Icense No <br /> Phone <br /> d ass ' <br /> Cprt ra[tor WELL REPLACEME T ❑ DESTRUCTION C] Out of Service Well G! <br /> TYPE OF WELL/PUMP. NEW WELL ❑ OTHER ❑ Monitoring Well U <br /> PUMP 1NSTALLATIOt> SYSTEM REPAIR L7 <br /> SEWER LINES �---- DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC T OTHER WELL PITS/SUMPS <br /> _ <br /> FOUNDATION <br /> IDN �- AGRICULTURE WELL <br /> INTENDED USE TYPE OF WELL PROBLEM-AREA CONSTRUCTION SPECIFICATIONS pia. of W <br /> Bottom ell Casing <br /> ❑ an <br /> ❑ Open BotManteca Dia. of Well Excavation <br /> Cl Industrial Type of Casing Specifications <br /> domestic/Private ❑ Gravel Pack ❑ Tracy Type of Grout <br /> S 1 Other ❑ Delta Depth of Grout Seal r` <br /> I I'1 Public + $ dace Seat'Installed by <br /> I I Irrigation _.ApQrox.'Dep h Eastern f <br /> H.P. t ate r on <br /> Repair Work Done L7 Type of Pump 'A!D th �— O <br /> Sealing Utaterial, � eP <br /> Well Destruction ❑ Well Diame <br /> Depth Filler Material &'Depth h <br /> Dep septic sstem permitted if public sewer is <br /> I� TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIRlAOD1TION I i DESTRUCTION I I availab a within 200 feet <br /> r <br /> Installation will serve: Residence •�"Comercial Other, <br /> `Number of bedrooms <br /> Number of living units: r -Water table depth Q <br /> Character of sail to a depth'of 3-feet:• - - f <br /> No. Compartments <br /> SEPTIC TANK . ❑"$ Type/Mfg apacity— <br /> � <br /> 4 � T G' � Method of Disposal <br /> PKG. TREATMENT PLT:-❑ f , -" <br /> Distance�o nearest: Well Foundation Property Line <br /> Total length/size f <br /> LEACHING LINE LI No. &Length of Eines pra,— e <br /> FILTER BED rCI Distance t0 nearest: Well Fouridatian <br /> fi Number <br /> SEEPAGE PITS 11 3 Depth -Size r <br /> r . "" -Foundation' Property L J] <br /> SUMPS i Distance to nearest: Well Line <br /> F _ <br /> DISPOSAL PONDS ❑ y <br /> I hereby certify that I have prepared this application and-that the-work will D6 cone accordance with San Joaquin county ordinances, state laws, and <br /> done i <br /> not <br /> rules and regulations of the San Joaquin County: <br /> Home owner or licensed agent'sergas tarbecame subject wlorkmen'srtcoympensat on lthat in the awsoof Cal forrnia," Contractor s1h ri gI op sub-contracting nc signature ermit is issued, I shall <br /> employ any person in such <br /> � .�certifies the following: "t certify that in the performance_of.the work-for which this permit is issued,�l'shaN employ persons subject to workman s compens - <br /> k tion laws of California." e, <br /> The applica t call or r uifed irtspectitionns. Complete drawing on rev side., n <br /> b�J Titl Date: �S <br /> } Sig d <br /> FO DEPARTMENT USE ONLY e 1 <br /> r Dates Q- Area <br /> Application Accepted by <br /> �I Pit or Grout inspection by Date.. <br /> Final Inspection by Date <br /> 4 Additional Comments: <br /> I Applicant - Return 213 copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Se kions CA 95201 <br /> 1601 E. Hazelton Ave., P 0 Box 2009, <br /> i <br /> CK RECEIVED BY DATE PERMIT NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO_ <br /> + EM 13-24 MEV.I/H 51 <br /> EH 44.2e <br />