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APPLICATION FOR PERMIT .� <br /> r SAN JOAQUIN COTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E,' HAZELTON AVE. , PHONE (2'09)465-3420 <br /> r��P O BOX 2009, 'STOCKTON, CA1 95201 <br /> J!ERMR IT_ EXPIRES-!.YEAR MON DAI,E ISSUED <br /> -- (Complete in Triplicate) <br /> Application S's herebymade 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 /> I, Joaquin County Public Health Services. <br /> _ - [ [[�� � + <br /> - <br /> r <br /> � <br /> CJob Address ity Lot Size/Acreage <br /> Owner's Name y� +!' ,_ Add ess G� Phone �` D <br /> Contractor •V 1-- # � <br /> Addre`Ss .License No. 1l� phone <br /> TYPE OF WELL/PUMP_a "` E1N'I+yEtt❑' r WELL REPLACEMENT CJ DESTRUCTION Out of Service We1i ❑ <br /> f } PUMP NS,TAL {iTIONa❑�}, "s SYSTEM'REPAIR D OTHER C j Monitoring Well <br /> c <br /> { DISTANCE TO NEAREST: SEPTIC TANK SEWER ONES DISPOSAL FLO. PROP€ LINE <br /> I f FOUNDATION AGRICULTURE WELL. OTHER WELL PITSAUMPS <br /> INTENDED USE ! TYPE OF WELL PROBLEM AREA! CONSTRUCTION SPECIFICATIONS <br /> [I Industrial w ❑ Open Bottom ❑ Manteca Dia. of Well,Excavation ) Dia. of Well Casing <br /> N Domestic/Private C1 Gravel Pack ❑ Tracy Type of Casm Specifications <br /> f'1 Public �y__w <br /> 1-1.!Q"hr n Delta Depth of Grout Seal Type of Grout <br /> I i IrrigationApprox.,Depth 11'Easte►n Surlace Seal Installed by T <br /> i <br /> Repair Work Done U Type of Pump - H.P. St to Work D ie + <br /> Welt Destruction Well Diameter Sealing Material & Depth <br /> Depth i �� Filler Material S Depths A <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION t I DESTRUCTION I (No se tic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence J Commercial_ Other r <br /> i <br /> Number of living units: Number of bedrooms ' <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No]Compartments <br /> C PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line i <br /> LEACHING LINE ❑ No. & Length of lines Total length/size — <br /> FILTER BED Cl Distance to <br /> nearest: Well Foundation Property Line i <br /> SEEPAGE PITS l I Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ •E 4� i F <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin,county ordinances;stati1`aws,-and <br /> rules and regulations of the San Joaquin[County + . .1 <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work;fo1,fi h this permit is issued;.I=shalt:notes <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting-sien6re <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 compansa- 0 <br /> tion laws of California." 4 <br /> The applicant requir ons:Complete drawing on rev [s�side. <br /> Signed Title: �J Date: <br /> F.O&DEPARTMENT USE ONLY <br /> Application Accepted by16- Date +� } � Area { <br /> r <br /> Pit or Grout Inspection by Date Final Inspection by M ��.__7I <br /> Additional Comments: t <br /> v <br /> Applicant — Return all copies to: ISan Joaquin County Public Health r <br /> 11601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE I AMOUNT REMITTED-, cic A wRECEl1/Et] V �" s� <br /> INFO ,1 ! CAS FL v g rQ4TE PERMi7yND <br /> 32 <br /> meg! F <br /> H-4 4.26-------_ <br />