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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, <br /> ENVIRONMENTAL HEALTH DIVISION S <br /> 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PEIWIT EXP RES 1 YEAR FROM DATE ED <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 Services. <br /> Job Address <br /> 4/, City L- _L Lot Size/Acreage <br /> /J� <br /> Owner's Nam / Address �� ' `'' Phon,Jz �_5 w <br /> I <br /> Contractor 'fG Address / License No.��Phone / <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Fl DESTRUCTION ❑ Out of Service We11 ❑ <br /> PUMP INSTALLATi(). 1. SYSTEM REPAI� OTHER O Monitoring Well [3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE <br /> FOUNDATION_ _..AGRICULTURt WELL 4 :'�QTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl Industrial El Open Bottom ❑ Manteca Dia. of We Excavation Dia. of Well Casing <br /> F] Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications <br /> I'i Public 1-1 Other n Delta Depth o GroutY 'eat Type of Grout <br /> Iy+rtiljallon _..Approx. Depth { I Eastern S r1,5.Qul Inslied by <br /> Repair Work Done 0 Type of Pump X61'4 H.P. State Work Done <br /> Well Destruction O Well Diameter Sealing Ma erial Depth <br /> i I± <br /> Depth Filler Materiel&'Deph <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is <br /> 9 available within 200 feet.I <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 depth <br /> SEPTIC TANK. O Type/Mfg - .,Capacity No. Compartments <br /> PKG. TREATMENT PLT. <br /> El <br /> of Disposal <br /> Distance to nearest: Well Foundation 9 Property Line <br /> f <br /> LEACHING LINE ❑ No. & Length of lines Total"length/size <br /> FILTER BED ❑ Distance to nearest. Well Foundation - Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS 0 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ t` <br /> t " <br /> I hereby cenify that I have prepared this application and that the work will be done in a Lordance 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 peraon i ;such manner as to become subject to workman's compensation'per <br /> of California." Contractor's(tiring or sub-contracting signature <br /> certilis'the followin : "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 alilo5hia." <br /> The appfi nt m tal for all tgquired ' s tions. Complete drawing on reverse side. <br /> Signed T��/ Title: Date: 1 <br /> I <br /> R DEPARTMENT USE ONLY C� <br /> Application Accepted by Date R. --— Area <br /> Pit or Grout Inspection by Date Final Inspection by iL Y►'� - - Dats <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 CKRECEIVED BY DATE PERMIT'NO, <br /> INFO CASH <br /> a EH 13-24(REV,r/Mw Wlyj 1grv tI� OC7 ZqO <br /> EH 14.29 ll.?? <br />