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APPLICATION FOR PERMIT <br /> ' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES .. <br /> IJ ; ENVIRONMENTAL HEALTH DIVISION <br /> ' 1601 E. HAZELTON AVE. , PHONE (209)468-3420 v <br /> P`O BOX 2009, STOCKTON, CA 95201 <br /> PE-MIT EXPIRES 1_YEAR FR M DAT uED <br /> (Complete in Triplicate) <br /> Application is hereby made.to Sen 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 /> ``�� i <br /> Job Address rg,=a `� '����1"-� - -- City A � Lot Size/Acreage a r 4 <br /> Owner'ti`Nam' Q �+ t t Address0°D3Q Phone 3 10 <br /> t <br /> C I�� o l n Address fJQk► <br /> Contractor } License lyo Phone <br /> . .� --- ! <br /> TYPE OF-WELL/PUMP: - NEW 1111ELL ❑ WELL REPLACEMENT ❑ D@STRUCTfON ❑ Out of Service Well <br /> PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> e <br /> JM: FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> __-`,-INTENDED USE I . TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Weli,Casing <br /> Cl Domestic/Pfi4te I I ❑ Gravel Pack. ❑ Tracy Type of Casing Specifications <br /> 1'I Public -1 Other fl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation .I i _ Approx. Depth I I Eastern Surface Seal Installed by <br /> fiepair.Work DoneY U ',Type of Pump H.P. State Work Done ' f <br /> Well'Destructian ❑ Well Diameter —Sealing-Plat@ril'li Depthx^^'"' "� :; ' <br /> Depth Filler Material b Depth , <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIRIADDITtON I 1 DESTRUCTION I 1 INo septic system permitters if public sewer is <br /> available within 200 feet.s <br /> t <br /> Installation will serve:1�Residence= Commercial Other <br /> Number of living units;Illl Number of bedrooms <br /> Character of soil to a�epth of 3 feet: Water-table depth <br /> SEPTIC TANK Type/Mfg Capacity- No. Compartment <br /> PKG+,TREATMENT PLAC7 � , Method of Disposal <br />_ r Distance.to nearest: Well Foundation Property Line <br /> LEACHING LINE ; L1' No:.A Length of lines Total length/size <br /> FILTER BED , ❑ Distance to nearest: Well Foundation Property Line <br /> ' - a <br /> SEEPAGE PITS i I' Depth Size Number y'I <br /> SUMPS Ll Distance to nearest: Weil Foundation Property Line <br /> DISPOSAL PONDS I ❑ f� <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordin/ances, state laws, and <br /> rules:and rdoulat ons of the'San Joaquin County <br /> Home owner or ficensed'�gent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall t <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signatur 1 <br /> certifies the following: "Ilcartify 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.":I� <br /> r` <br /> The applicant must call for all required • spections. Complete drawing on reverse side. <br /> Sign dV AV <br /> II` Title: e4_ Date: <br /> FOR DEP RTMENT USE ONLY <br /> Ik r if <br /> Application Accepted by Date Area <br /> III i <br /> Pit or Grout Inspection by. Date Final Inspection by Date�1 <br /> Additional Comments: I� - <br /> IApplicant - Returnahll copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> t 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, GA 95201 <br /> r IFEE NFO �f AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'N0. <br /> .I h 88 <br /> . EH 1324 IAEV.I h 51 EH:4.20 V�Ph <br /> -- ii <br />