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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 /> PIkHMIT 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 1s 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 ''� T�/k/3 r ��lJN City —0 evLot Size/Acreage <br /> Owner's Name%ZO C:/c 1JzC_(—r e4 Address q) %TirJIW eAPLCJIt, y_- Phone-,511�" q 0 7 <br /> ContractfltAddress I?U xsa License Na, Phone 2`Vl1 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR 0 OTHER ❑ Monitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE \ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial Q Open Bottom C] Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications <br /> [I Public l-] Other Cl Delta Depth of Grout Seal Type of Grout <br /> t I Irrigation _ _.Approx. Depth t I Eastern S?ce Seal Installed by <br /> S <br /> State Work Done Repair Work Done 7 Type of Pump H.P. [� <br /> 1 <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I i DESTRUCTION I i lNo septic system permitted if public sewer is <br /> available within 200 feet.I <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 ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. D Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED t=1 Distance to nearest: Wall Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size _ Number <br /> SUMPS El Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <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 cenifibs 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 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 persona subject to workman's compensa- <br /> tion laws of C ifornia." /� <br /> The applican must call for all requ' d 'hspections. Complete drawing on r�verse side. <br /> Signed Title: ._(A� � Date: // 4 c t <br /> RTMENT USE ONLY <br /> Application Accepted by ____ r Date �/�J�Z_� Area 0 1 <br /> Pit or Grout Inspection by Date Final Inspection byDate <br /> Additional Comments: <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 /> IPAI <br /> FEE AMOUNT DUE AMOUNT REMITTED CK 0 CASH RECEIVED BY A7E PERMIT'NO. <br /> + EH 13-20[REV.I)x 51 J/N <br /> EH 11.2e ! [ J w <br />