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1 <br /> APPLICATION FOR PERMIT r <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 71 1601 E. HAZELTON AVE. , PHONE (209)468--3420 <br /> P O BOR 2009, STOCKTON, CA 95201 <br /> MIREg 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 compliance with San Joaquin County Ordinance No. 549 and 1$6 and the Rules and Regulations of San f <br /> Joaquin County Public Health Services. " '94 <br /> / } <br /> Job Addresses 7// City Lot Size/Acreage / <br /> Owner's Name ./�l �r - Phone <br /> Contractor e�ss cense N0..' Phane <br /> TYPE OF WELL/PUMP: 0. NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION LVOut of Service We-11 CT <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C] OTHER ❑ Monitoring Well U <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER EINES DISPOSAL FLD. - PROP. LINE <br /> FOUNDATION }= AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom' <; ❑ Manteca. Dia. of Well Excavation Dia. of Well Casing § <br /> D Domestic/Private Cl Gravel Pack Ll Tracy Type of Casing Specifications <br /> F1 Public n Other ❑ Delta Y Depth of Grout Seal Type of Grout <br /> I i Irri ation A r <br /> g _. pprox. Depth f I,Eastern AlSurface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth : i Piller Materiel & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I i INo septic system permitted if public sewer is <br /> _ available within 200 feet.i <br /> Installation will serve: Residence Commercial Other <br /> I <br /> Number of living units: f Number of bedroomsig _ <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. ❑ y' Method of Dispose <br /> Distance to nearest: Well Q 0 "111 Foundation 90 Property Line © o <br /> LEACHING LINE ❑ No. $ Lengthrof lines Total lengthlsiza ; <br /> FILTER BED C1 Distance to nearest: We' 4Q_ IFoundation���i Property LineI Fl a=i= <br /> SEEPAGE PITS 11 Depth b A izeNumber `f�� <br /> UMP L I Distance to nearest: Well Foundation— Property Line!� <br /> ISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work 11,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; "I certify that in the performance of the work for which this permit is issued, I shall not Ys` <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." I <br /> The applicant must call for all requi spections. Comple drawing on verse side. <br /> Signed Title: Data. / _/Z <br /> a t/ <br /> i <br /> r f FOR DEPARTMENT USE ONLY <br /> Of <br /> Ap cation Accepted by .� _ _ f Date <br /> ' Area <br /> /Pit pr Grout Inton by Datef G Final Inspection by Date Q <br /> .Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hatelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE INFO AMO/U�N/T'IdOE .AMOUNT REMITTED CK 9 CASH RECEIVED BY DATE <br /> h PERMI�T'NO. <br /> + EH <br /> 14.21 <br />