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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)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> RAWIT EXPIRES 1 YEAR FRQM DATE ED , <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 Health Services. r <br /> Job Address. ((,/ <br /> V• ity ~/ Lot Size/Acreage <br /> .*I�_14 t <br /> Owner's NameOF <br /> L /v f �- Ad�ss <br /> Contractor Address ` �/ r <br /> t' `�� / .. LicenseNo. et S Phatfe 'FJ �p . <br /> TYPE OF WELL/PUMP: - NEW WELL p 'WELL REPLACEMENT ❑ _ DESTRUCTION 0 Out of Service Well ❑ <br /> i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ %,'Monitioring Well U <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER'LINES DISPOSAL FLD. PROP. LINE j <br /> FOUNDATION _ T AGRICULTURE WELL OTHER WELL PITS/SUMPS r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I <br /> 1-1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> C) 1]omesticlPrivate� ❑ Gravel Pack ❑ Tracy Type of Casing- <br /> Specifications <br /> I'I Public X. C7Other fl pelta Depth of Grout SeaII Type of Grout . <br /> I I Irrigation x A.Approx. Depth [ 1 Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done __ 5 <br /> Well Destruction ❑ Well Diameter Sealing Material& Depth + <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION1 REPAIR/ADDITION I i DESTRUCTION I 1 INo septic system permitted if public sewer is 1 <br /> r available s:f <br /> within 200 feet. , <br /> Installation will serve: "Residence` Commercial_ Other { <br /> Number of living units: y Number of bedrooms— _f + <br /> Character of soil to a depth of 3 feet: Water table depth ` <br /> SEPTIC TANK. © 'Type/M1g G04Capacit � ,r7� <br /> Yom— _ No. Compartments <br /> PKG. TREATMENT PLT. Cl Method of Disposal <br /> Distance to nearest: Well I �_ Foundation Property Line , <br /> t <br /> LEACHING LINE ❑ No. & Length_of tines <br /> nearest: l <br /> Total length/size <br /> FILTER BED ID Distance to Wal ��Foundation <br /> ---� •rJC2 Property Property Line S <br /> SEEPAGE PITS [ I 'Depth_. �' Size k Number f <br /> SUMPS LI r Distance to nearest: Well U Fou�ation — <br /> _ Property Line <br /> DISPOSAL PONDS p $ — - + „� , <br /> X 9h" ZJ <br /> i <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 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, !-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 California." ; <br /> + + <br /> The applicant must calLiaLall ...cluke",mclions-.4CVMplate drawing on reverse side. <br /> Signed X. <br /> isle: Date; l <br /> EPARTMENx.l1SE ONLY <br /> Application Accepted by <br /> ate D <br /> I -- Area <br /> t Y <br /> Pit or Grout Inspection by <br /> Data Final Inspection by �p <br /> Date _ <br /> Additional Comments: <br /> i <br /> Applicant Return all copies to: San Joaquin County Public Health f <br /> Services; Environmental Health Permit/Services I <br /> 1601 E.AMOUNT REMITTEHazelton Ave., P x 2009, Stockton, CA 95201 <br /> FEE AMOUNT OUE D <br /> INFO CK RECEIVED BY DATE PERMIT'NO. <br /> + EN 19.24 IREV,r/MSI l �•+ I <br /> EH;4.26 <br /> r, <br />