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s t APPLICATION FOR PERMIT <br /> "{ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> ]601 E. HAZELTON AVE. , .PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED NOW <br /> (Complete in Triplicate) <br /> No <br /> Application is here � � <br /> � by made+to San Joaquin County fora permit to construct and/or install the work herein d�e,siir a This <br /> application is made in compliance with San Joaquin Count Ordinance 4 <br /> Y A o 5 9 and la62.and the Rules and Relations of San <br /> Joaquin County Public Health Service � <br /> Job Address City Lot Size/Acreage <br /> Owner's Na ah. Address .5 "' �a <br /> � Phone <br /> ti a <br /> Contractor ss I X05 - — �TM— -license Nof Q � -- - hone� 2- <br /> TYPE OF WELL/PUMP: NEW WELY❑ WELL REP CE IJ DESTRUCTION LI Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ _ SYSTEM RE IR ❑ OTRER ,Q Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER INES DISPOSAL FLD, �PROP.-LINE ` <br /> FOUNDATION AGRICUL URE IIU OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CO STRUCTlON SPECIFICATIONS <br /> M Industrial LJ Open Bottom Q Manteca ia. of Well Excavation Dia. of Well Casing <br /> I) Domestic/Private ❑ Gravel Pac;—,---.-L-1 Tracy----�- � ype of-Casing Specifications <br /> I'i Public € El Other � � Fl Delta epth of Grout Seal Type of Grout <br /> I I Irrigation _..ApproK, Depth I I Eastern S dace Seal Installed by <br /> Repair Work Done ❑ T p} <br /> P Type of Pum H.P: State Work pone <br /> Well Destruction O Welt Diameter Sealing Ma rial & Depth <br /> Depth t Filler Materl.1 A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION f I REPAIRIADDITION I I DESTR CTION K (Nos <br /> ePlic system permitted if public sewiyr is <br /> �+ � availabl ithin 2 fee ) J t, <br /> Installation will serve: Residence ji Commercial_ Other [J` <br /> Number of living units: Number of bedrooms 14 <br /> ` ` S <br /> Character of soil to a depth of 3 feet: <br /> , Water table depih f <br /> SEPTIC TANK. 0 Type/Mfg <br /> r ! i = <br /> Capacity No. Compartments <br /> PKG. TREATMENT PLT. E)) Method of Disposal <br /> Distance to nearest: Well Foundation Property Line (� <br /> f k <br /> LEACHING LINE ❑ No. & Length of lines Total length/size , <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> � � I <br /> SEEPAGE PITS 11 Depth j Size Number a ' <br /> SUMPS Cl Distance toynearest: Well Foundation Property-Line <br /> DISPOSAL PONDS ❑ _a <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 t ". ) <br /> Home owner or-licensed agent's signature' <br /> ignature{certifies the following: "I Certify that in the performance of the Workfor whichihiJpermit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation taws of California.-Contractor's hiring or sub-contracting signature <br /> cenifaws of Cthe lllowin is 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 /> F <br /> The appfica must call f required i psctions. Complete drawing on reverse side, <br /> Signed In a. Title: r <br /> Date: 0 <br /> f <br /> - _ <br /> IT DEPARTMENT USE ONLY: <br /> Applic tion Accepted by Date — Area - T� <br /> Pit or Grout Inspection by Date Final Inspection by Date f ( O <br /> _ r <br /> Additional Comments: <br /> f <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 `nom <br /> pUE AMOUNT REMITTEp CK RECEFVED BY DATE PERMfT'NO.[!JAMOUNT CASH ,� fEH 14.26 pfV.fiK31 r -V <br />