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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES Vvw . Cov <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> + ZERRMIT ERP RES 1 YEAR FROM DATE ISSUED �`�o�A! • <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. <br /> Job Address -- II'_ _ _ City S �✓. Lot Size/Acreage <br /> r <br /> Owner's Name F�1t -� Address ---- $ 7r Phone <br /> Contractor.—A94 I� ` Address _�}d �+ �/idt License No.&9f1/99 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well Gl <br /> PUMP INSTALLATION C1 SYSTEM REPAIR .❑.._. _ .._ _OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE �y <br /> FOUNDATION AGRICULTURE WELL OTHER WEL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFISe6A <br /> C] Industrial V �.- Q,Open Bottom ❑ Manteca Dia. of Well Excavati Dia. of Well Casing <br /> F]] Domestic/Private, <br /> '.,❑ Gravel Pack ❑ Tracy Type'of�Casi Specifications <br /> I'l Public 1-1 Other n Delta Dep ,Grdui}Seal Z � k � � Type of Grout <br /> �.� <br /> I I Irrigation _..Approx. Depth l I Eastern. r�-.- _ urfJoe-Seal <br /> Repair Work Done U Type sof Pump = H.P State Work Done ' <br /> Well Destruction ❑ Wel! Diameter alin8 Material & Depth t <br /> Depth iller Material & Depth f <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTIlNo septic system permitted if public sewer is <br /> 1� available within 200 feet.) <br /> Installation will serve: Residence— Commercial Other <br /> Number of living units: �: Number of bedrooms <br /> Character of soil to a depth of 3 feet: ) — - -- - - Water table depth <br /> SEPTIC TANK 0 Type/Mfg i Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ w1 Method of Disposal <br /> Distance to nearest: Well Foundation r l' Property Line <br /> LEACHING LINE 0 No'. & Length of lines Total length/size { <br /> FILTER BED 0 Distance to nearest: Well Foundation=, Property Line <br /> SEEPAGE PITS ( I Depth Sire t Number <br /> SUMPS Irl Distance to nearest: Well Foundation i.—t 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 /> rules and regulations of the San 'Joaquin County i <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 <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring'.or subcontracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons sub ct to workman's compensa- <br /> tion laws of California." <br /> The applicant mu call for all required ins ctio s. Complete drawing on reverse side. <br /> Signed X Title: . Date: <br /> H DEPARTMENT USE ONLY <br /> Application Accepted by Date�� ` , Area 8 <br /> Pit or Grout Inspection by II� Date Final Inspection by „Sr Date <br /> Additional Comments: <br /> 7� <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMfTTED CAS RECEIVED BY DATE PERMI-r NO. <br /> + EH13-24 IREv.r/e 51 IQ d <br /> EH 14.26 <br />