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APPLICATION FOR PERMIT <br /> g7f7 <br /> � 1 <br /> i� 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 EXPIRES 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 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. �j ,�,,/ <br /> Job Address Mu�uy��� •ter City of Size/Acreage <br /> Owner's Nam /e - a/ Address ,'�_4Z 521 Phone <br /> Contractor Address al&c- J �%7~*' License No. DMZ Phone <br /> j TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well 0 <br /> PUMP INSTALLATION 0 SYSTEM REPAIR 411' OTHER 0 Monitoring Well a <br /> f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C__] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> GI^13omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'1 Public Cl Other n Delta Depth of Grout Seal I Type of Grout <br /> I I Irrigation Approx. Depth I l astern Sud ce Seal Installedfby <br /> Repair Work Done Ill Type of Pump :5 <br /> H,P. / State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth i <br /> TYPE OF SEPTIC WORK: NEW—INSTALLATION-1 I _REP'AIWACOITION1-1" 'DESTRUCTION I 1 INe septic system permitted it public sewer is <br /> Installation will serve: Residence— Commercial_ OtOer—— <br /> I available within 200 feet.) <br /> Number of living units: t Number of bedrooms J + y <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK E3 Type/Mfg I:: J Capacity No. Compartments <br /> PKC. TREATMENT PIT, ] "__J f Method of Disposal <br /> Distance to nearest: Well Foundation i PI roperty Line <br /> LEACHING LINE L1 No. & Length of lines Totai,{ength/size <br /> r <br /> FILTER HED n Distance to nearest: Well Foundation f ' Property Line <br /> SEEPAGE PITS 11 Depth Size E Number <br /> t 01 <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ F`r <br /> I hereby certify that I hav ared this application and that the work will be done in accoidance'with San Joaquin county ordinances, state laws, and <br /> rules and regulation the San aquin County <br /> Home owner or I' eased agent's si nature certifies the following: "1 Certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any pe on in such mann as to bec me sub' to workman's compensation laws of California," Contractor's hiring or sub-contracting signature <br /> certifies the f Ilowing: "I certif at i he o of the work for which this permit is 4sued,"A shall employ persons subject to workman's compensa- <br /> tion laws o Californi s -The applic nt m f all re plete drawing on r side, <br /> 00, <br /> Signed X. Title: Date: O <br /> �FOREPARTMENT USE ONLY <br /> C-b <br /> Application Accepted by Date Ares <br /> r 3 <br /> Pit or Grout Inspection t Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health �t <br /> Services, Environmental Health Permit%Services �. <br /> 1601 E. Hazelton Ave., P 0 Box 2009,18t6ckton, CA 95201FEE <br /> INFO MOUNT DUE AMOUNT R MITTED CASH CK AT RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-24(REV,t92 a <br /> EH 1440 t <br />