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APPLICATION FOR PERMIT <br /> 'SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> I ENVIRONMENTAL HEALTH DIVISION ` <br /> 1601 E. HAZELTON AVE. , PHONE (209)468--3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 ID <br /> SIT EXPIRES 1 YEAR FROM DATE I5..aUED <br /> (Complete in Triplicate) <br /> P ) <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 1662 and the Rules and Regulations of San <br /> Joaquin County Public <br /> Health Services. <br /> Job Address �`� Al, 6e4Yd L <br /> City �<���"� Lot Size/Acreage <br /> Owner's Name / <br /> Address /,;�p �✓� S C1z�c6�- Ve- Phone <br /> Contractor_. _ I Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service We Ll <br /> INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLU, PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing <br /> 11 Domestic/Private 0 Gravel Pack 0,Tracy Type of Casing Specifications.` - <br /> i'1 Public Ll Other1 1­1Delta Depth of Grout Seal Type of Grout . <br /> I i lirivation —.Approx,{Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth �. <br /> Depth Filler Material & Depth <br /> TYPE.OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTIONNo septic system permitted it public sewer is <br /> I <br /> Aavailable within 200 feet.) i <br /> Installation will serve: Residence_ Commercial— Other 6 3! <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 Typ t. No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal I <br /> Distance to rmlttmay fla'JB Property Line ' <br /> LEACHING LINEt El No. $ v�tifryl Il UI ! Total length/size <br /> FILTER BED C7 Distancvey,tloYinee yr)Q�tSyerrL `# cDhd80t0R` Property Line <br /> SEEPAGE PITS '• 11 Depth VSize Ilf I I': Number <br /> SUMPS LI 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 county ordinances, state laws, and <br /> rules and regu{aeons 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." 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 Califor <br /> The applicara mus for all req ed inspections. Complete drawing on reverse side. <br /> Signed X Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> // <br /> Application Accepted by Date -0�ql <br /> Area -2-1 <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: ' lu- /Up cqr/ yy�� <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 PERMIT NO. ` <br /> INFO CASH <br /> . EH 13-24{REV.i/nsl [ �1— }��(/- <br />