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APDL I CATION. FOR PERI[I T <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I' <br /> i ENVIRONMENTAL HEALTH DIVISION <br /> 1601 F. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOR 2009, STOCKTON, CA 95201 I i <br /> ZEMIT EXPIRES 1 YEAR FROM DATE <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 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Servilces. c <br /> . 6 City J Lot Size/Acreage ��� <br /> Job Address p <br /> Owner's Name Address $ Phone �y 7I4 S <br /> -��Vl <br /> Contractor- �d t/,txK_ I Address "�� " License No. Phone <br /> TYPE OF WELL/PUMA: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR ❑ OTHE Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES DISPOSAL FL PROP.-LINE- <br /> FOUNDATION AGRICULTURE WELL OT LL PITS/SUMPS ;1 <br /> INTENDED USE F WELL PROBLEM AREA CON STRUC PECIFICATIONS <br /> n Industrial ❑ Open.Botto ❑ Manteca Pia ell Excavation Dia. of Well Casing <br /> Ca Domestic/Private Cl Gravel Pack ❑ ra Type of Casing— <br /> th of Grout Seal Type of Grout <br /> I'l Public f.1 Other' r! fl ,, <br /> I I Irrigation x Approxi De 1 1 Eastern Surface a tailed by <br /> Repair Work Done 0 Type of p , H.P. Work Done <br /> Well Destruction ❑ e I Diameter Sealing Materiel & Depth - _ <br /> Depth <br /> Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I i DESTRUCTION lNo septic system permitted if public sewer,is 11 <br /> available within 200 feet.) <br /> Installation will serve: Residence" Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depot + <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments li <br /> PKG. TREATMENT PLT. ❑ '' k Method of Disposal. <br /> Distance to nearest: Well Foundation Property Line <br />� LEACHING LINE CINo. & LeTotal lenth/sizeingth of lines 9 <br /> FILTER BED ❑ Distance; nearest: .Well Foundation Property Line <br /> u <br /> SEEPAGE PITS I I Depth - tT' Size Number U. ' <br /> SUMPS Ll Distance'& nearest: Well Foundation Property Line <br /> k DISPOSAL PONDS 0 t �� <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 regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to,become sub' to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the perfocma ca f the work for which this permit is issued,f shall employ persons subject to workman's compensa- <br /> i tion laws of California." r <br /> The applicant for ally ired in I t' C mplate drawing on reverse side. <br /> Signed e. Date: <br /> DEPARTMENT USE ONLY Ir <br /> Application Accepted by <br /> Date a Area I <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> r <br /> : Applicant - Return all copies to San Joaquin County Public health <br /> t { Services, Environmental Health Permit/Services Vd` <br /> 4 1601 E. Razelton Ave., P 0 Box 2009, Stockton, CA 95201 Ate` <br /> FEE AMOUNT DUE AMOUNT REMITTED CAS RECEIVED BY DATE PERMIT'NO. <br /> INFO r /' <br /> + EH 13-24(REV.r I n 51�' L7�� �-'�� `_0 <br /> EH S4•26 <br />