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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 O BOR 2009, STOCKTON, CA 95201 <br /> -PRERMIT EXPIRES 1 YEAR FROM DA2,'E IS_S_UED <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 Na. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> �3( ej <br /> Job Address Cityyt2L14Lot Size/Acreage <br /> Owner's Name Address r Phone <br /> Contract r Address t p.rLR ���'� ,�� c� p f <br /> �;_ � PL _`�Z�License Roza ZZ� Phone O `�� <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT.0 DESTRUCTION ❑ Out of Service f1e11 ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well i7 I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE j <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ! <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I <br /> C7 Industrial ❑ Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Ca Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing r Specifications <br /> I'1 Public 1-1 Other n Delta Depth of Grout Seal ° Type of Grout <br /> I I Irrigation __.Approx. Depth I I Eastern Surface Seal installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done Y 6 <br /> Well Destruction ❑ Well Diameter Sealing"Material b Depth -- i <br /> Depth Fiiier Materials _b1. hDepth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t I EPAIR! DDITIONY DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.! <br /> Installation will serve: Residence _Commercial Other € Y <br /> Number of living units: . . Number of b rooms <br /> Character of soil to a depth of 3 feet: Watei"table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity__:'__ No. Compartments <br /> PKG. TREATMENT PLT. ❑ f- - �4 <br /> s _ Method of Disposal <br /> Distance to nearest: ;Well - Foundation" Property Line <br /> Dulv <br /> _ No. & Length of lines Total length/size K a X <br /> FILTER BED-Y ❑ Distance to nearest: Welf _ Foundation — ,Ll�_ Property Line 1 <br /> SEEPAGE-PITS I i Depth Size {` Number~ <br /> SUMPS` _ LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL`PONDS 0 <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: "1 certify that in the4performance of the work for which this permit is issued, I shall 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 is issued; I shall employ persons subject to workman's compensa <br /> tion laws of California..'-'- . .. 14 <br /> The applicant t call for a r uir d inspections. Complete drawing-an reversegid {� <br /> Signed Title: �il _ <br /> - Date: <br /> FOR DEPARTMENT USE ONLY I <br /> Application Accepted by © Dat�C 6 <br /> ,,� Area 2� <br /> Pit or Grout Inspection by Date Final Inspection byu�►,v� Date_ <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental 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 PERM17'NO. <br /> INFO CASH <br /> + EHc3-21IREV.iixsl l <br /> EH r(� �I / <br /> t�•2e <br />