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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)46$--3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT E%P RES 1 YEAR EROM A E <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 He/a, th Sery es. q <br /> Ci A_4<LQ�Size/Acreage <br /> Jab Address <br /> Owns's Nam cess r <br /> Phone <br /> Contrao or T Address Icense No. Phone ~� <br /> TYPE OF VVELL/PUMP. NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION <br /> SYSTEM REPAIR 0 OTHER ❑ Monitoring Well 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _Y <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS w <br /> 0 Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> rsticlPrivate 0 Gravel Pack 0 Tracy Type of Casing Specifications-- -- <br /> I'1 Public ! I:1 Other ( 1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrioation Approx. De 4 I Eastern Surface Seal Installed by <br /> Repair Work Done 0' Type of Pump H.P. � State Work Done <br /> Well Destruction 0 Well Diameter Sealing Material & Depth <br /> i Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ( I REPAIR/ADDITION I I DESTRUCTION I I (No sept er is <br /> E V E t <br /> Cf <br /> G <br /> IavailableInstallation will server Residence_ Commercial Other': ,rte f+ <br /> Number of living units: Number of bedrooms # -AUG-1,0 E � <br /> Character of soil to a depth of 3 feet: ' � � <br /> � <br /> fil.�e <br /> H <br /> SEPTIC TANK ❑ Type/Mfg Capacity- <br /> PKG. TREATMENT PLT. 0Meth <br /> epos <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED C1- Distance to nearest: Well ' Foundation Property Line r <br /> SEEPAGE PITS VI Depth Size Number <br /> It SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ 4 _ _v_. <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 /> l 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 shalt not <br /> f 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 /> I 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."; ` <br /> The applicant ust call to Complete drawing on revers de. <br /> III <br /> s <br /> f Title: Date: <br /> X <br /> Sign <br /> f3 DEPARTMENT USE ONLY <br /> -90 <br /> Application Accepted bi Date A/ Area r <br /> Pit or Grout Inspection by Date Final Inspection by Date z <br /> t ' <br /> Additional Comments: ' <br /> Applicant – Return all copies to: San Joaquin County Public Health n <br /> Services, Environmental Health Permit/Services <br /> i ! 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH CK 8 RECEIVED BY DATE PERMI7*NO. <br /> INFO <br /> . EH 13-24 ISM r/„51 <br /> EH 54.26 <br /> 1 <br />