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f APPLICATION. FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> k ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT XPIRES 1 YEAR FROM DATE ISSUED <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 cmiliance with San Joaquin County Ordinance No. 549 and 1$62 and�heulesand Regulations of San <br /> Joaquin County Public Health ervices. <br /> Job Address Cityit"_ Leage <br /> ti0 n`eF:sffYame-1 t.f' o Address �5-7 Phone _(_ 77Sol <br /> .t <br /> Co'n�tra�otC�'if v J Address <br /> .. license No. _-3,7- G_'Phone <br /> r <br /> �A 'tiTYPE,OF_WELU/FUMP:a-(a&`1 l NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION,0 Out of Service well ❑ <br /> PUMP INSTALLAT0 �i ❑ <br /> ION ❑ SYSTEM REPAIR j Monitoring Well C7 <br /> J• t.! ,�, .s Fri )-:0THEB.4. <br /> DISTANCE TO NEAREST:jSEPTIC TANK SEWER-LINESDISPOSAL FLD. PROP' INE , <br /> FOUNDATION AGRICULTURE-WELL OTHER WELLS PITS/SUMPS <br /> i,)--4 (INTENDED VSEI �TYPE OF WELL PROBLEM AREA CONSTRUCTfON-SPECIFICATIONS i <br /> C7 Industrial ❑-Open Bottom ❑ Manteca %waDii.'of Well Excavatibn' Dia- of Well Casing <br /> f] Domestic/Private EI,Gravel Pack ❑ Tracy Type of Casingg ' , 1 <br /> - pecifi%ations <br /> i'1 PublicOrt) Cl Delta 4- --Depth-of-Grou�af;IEIIv' ~`TYP,e'of Grout <br /> I I Irrigation _Approx. Depih*,.I I Eastern Surface Soul Ihstalfed by <br /> Repair Work Done ❑ Type of Pump :. H P f' State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Materlal I Depth <br /> Depth Filler Material A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial ther <br /> Number of living units: � Number of be o ms 1 <br /> Character of soil to a depth of 3 feet: —Water table depth <br /> SEPTIC TANK � Type/Mfg Capacity �No. Compartments <br /> PKG. TREATMENT PLT. ❑ l <br /> r "•'Method of Disposal <br /> Distance to nearest: Well Foundation _ Property Line S , <br /> t . <br /> LEACHING LINE ❑ No. & Length of lines Total length/size r <br /> FILTER BED ❑ Distance to`nearest. Well Foundation <br /> Prop <br /> eily Line <br /> SEEPAGE PITS 11 Depth I Size Number A- i <br /> SUMPS Cf Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin counEE3 <br /> ty ordinances, state laws, and r <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 subject to workman's compensation laws_of-California,..,' Contractoes hiring oL sub:contrActing_signature___y <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ l <br /> tion laws of California." m p y persons subject to workman's compense- <br /> The applicant t call for a aqui d inspections. Complete drawingon reverse sid <br /> Signed X � f v <br /> Title: �/ Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by ex,,L i i CIS <br /> Date lig Area <br /> Pit or Grout Inspection by Date Final Inspection by Date � <br /> Additional Comments: <br /> Applicant - Return all copies to: $an Joaquin County Public Health <br /> Services, Environmental Health'Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> j <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED aY DATE PERMIT NO. <br /> INFO CASH <br /> . EH 13-21 fNfV.1/n51 <br /> EH Z <br />