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APPLICATION FOR PERM I T <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOA 2009, STOCKTON•, CA 95201 <br /> PFIWIT- EXPIRES x YEAR FROM DATE <br /> (Complete in Triplicate) - <br /> Application is hereby made to Ser► Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is trade in compliance with San Joaquin County Ordinance No. 5h9 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address _ '72:Z �-�J� � City�'J.�l__ � �� bot Size/Acreage <br /> r <br /> Owner's Name _ x s 8 PIZ 666 Address Phone <br /> Contractor l45R Address f 6, Z . ,-YZdA _ <br /> License rvor��_Phone <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT M- DESTRUCTION ❑ Out of Service Well ❑' <br /> ' PUMP INSTALLATION C1 SYSTEM REPAIR 0 OTHER 0 Monitoring Well � <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial © Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> [I Domestic/Private ❑ Gravel Pack .0 Tracy_. _ _Type of Casing Specifications <br /> 1'1 Public El OthQr.,ti ., :� , F1 Delta Depth.of Grout.Seal Type of Grout <br /> I I I Irrigation Approxi Depth I ) Eastern Surface Seal Installed by <br /> 1 Repair Work Done U Type of PurSip _H.P-. $tate Work Done <br /> Well Destruction ❑ Well Diameter Well Material & Depth <br /> = Depth i Filler Material"a& Depth <br /> i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION? ffPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted it public sewer is <br /> 3 available within 200 feet.) <br /> Installation will serve: Residence k�-'Crommercial Other <br /> ' Number of living units: _� Number of bedrooms_ — %y <br /> Character of soil to a depth of 3 feet: ) Wafer table depth <br /> 'SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PIT. ❑ s - -. <br /> � 1� Method of Disposal <br /> Distance to nearest: Well 0�ft Foundation ---99�0__ __ Property Line ' <br /> ;LEACHING LINE No. Length of lines Total''lerrgth/size F <br /> FILTER BED I--1 Distance to nearest: �' Well /,ft Foundation - 'Property Line i2o <br /> SEEPAGE PITS PITS I I Depth Size Number- <br /> 1 SUMPS LI Distance to nearest: '- Well Foundation A operty i>e;.w� <br /> jDISPOSAL PONDS ❑ <br /> :I hereby certify that I have prepared this,application and that the work will be done in accordance with SanJoaquin:couhtiy.ordinances,'state laws, and <br /> rules and regulations of the San Joaquin County <br /> t Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work,for 114h this permit'is issued. I shall not <br /> employ any person in suctf manner asp become subject to workman's'oompe sation laws of California." Connector's hiring or sub-con't'racting signature <br /> certifies the following: "f certify that in the performance of the work for which this permit is issued, I shall employ persons subject tnworkrimm's compensa" <br /> ;tion taws of California." I 1` <br /> ..., •tom s.„ ;� � �, <br /> The applicant must CaLf or.all-required inspections. Complete drawing on reverse side. <br /> F i <br /> Signed X__ _z'z-' _;' Title: Date: <br /> t r <br /> FOR DEPARTMENT IISE ONLY, �' D <br /> Application Accepted by �l'� t h -• - Data � Area <br /> Pit or Grout Inspection by d Date ,Final Inspection try Data 1 <br /> Additional Comments: ; <br /> Applicant - Return all copies to: . San Joaquin County Public Health }w •• ' <br /> Services; Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., -P 0 Box 2009, Stockton, CA 95201 <br /> FEE "`AMOUNT t3t1E' AMOUryTREMf7E SCK` tl��` RECEIVED BY DATE PERMIT'NO. <br /> EH ti-24[REV. <br /> INFO CASK r ( Q <br /> . <br /> EH 54.20 <br /> 3 <br />