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APPLICATION FOR PERMIT <br /> SAN ,IOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 p•0 BOX 2009, <br /> L �VE. , PHONE STOCKTON, CA 95201 <br /> 0 EXPIRES 1 YEAR FR M DA E <br /> (Complete in Triplicate) <br /> by made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> Application is here <br /> San <br /> application is made inHeowhiance with San Joaquin County Ordinance No. 5k9 and 1862 and the Rules and Regulations14�� <br /> Joaquin County ( ¢ <br /> A� o L �[/�/ ("/� T City 5� Lot Size/Acreage <br /> KJob Address Al <br /> V ` Address (7���/�/V l�l � Phone G <br /> li wner's Name <br /> YS [ <br /> License No. — Phone <br /> Contractor Address WELL REPLACEMENT C.7 DESTRUCTION ❑ Out of Service Well ❑ <br /> NEW WELL ❑ OTHER ❑ Monitoring Well [3YPE OF WELLIPUMP. <br /> PUMP INSTALLATION O ?,MpSYSTEM REPAIR <br /> SEWER LINES•_-----...DISPOSAL FLD• PROP. LINE <br /> DISTANCE TO NEAREST:'SEPTIC TANK ��— OTHER WELL�� PITS/SUMPS <br /> FOUNDATION �� AGRICULTURE WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Lpia of Well Casing <br /> Bottom❑ Open Boto ❑ Manteca Dia. of Well Excavation <br /> ❑ Industrial G] Tracy Type of Casing Specifications to <br /> (:1 Domestic/Private ❑ Gravel Pack t Seal Type of Grout <br /> I:� <br /> Other Depth of Grout a <br /> Cl Delta �, <br /> ('I Public - "'"""'—Surfaci Seal Installed tsy <br /> 11 it6gation —Approx. Depth I I Eastern" State Work bone <br /> H.P t I <br /> Repair Work Done U Type of Pump a Sealing Material b Depth <br /> { Weil Destruction ❑ Well Diameter _ Filler Materiel & Depth <br /> Depth <br /> l TYPE 11 OF SEPTIC WORK: NEW INSTALLATION I I. REPAIRlADDITION I I DESTRUCTION I i avaik ble1within 200 feetc system .) if public sewer is <br /> m <br /> I Installation will serve: Residence Commercial ^Other �--- L <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK. ❑ Type/Mfg Capacity_ ------ <br /> Method of Disposal <br /> j PKG. TREATMENT PLT. Cl Property Line <br /> E1 Distance to nearest: Well Foundation __�__�.— <br /> t Total length/size <br /> r LEACHING LINE Cl No. & Length of lines Property Line <br /> FILTER BED Cl Distance to nearest: Well Foundation <br /> + Size Number <br /> j SEEPAGE PITS f I depth Property Lina <br /> SUMPS LI Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ <br /> nd that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application a <br /> rules and regulations of the San Joaquin County <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, l shall not <br /> { such manner as to become subject to woikman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> employ any person in si of the work for which this permit is issued, I shall employ persons subject to workman's compansa- <br /> certifies the following: certify that in the performanc <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> M t Date: <br /> Title: <br /> Signed X <br /> I F R DEPARTMENT USE ONLY <br /> Data rea <br /> f Application Accepted by <br /> ' Final Inspection b Date <br /> t <br /> Pit or Grout Inspection by Date <br /> r Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> i 2-/'J1-12--I.aF --vz e-F o r�v 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> CK RECEIVED BY DATE PERMIT NO. <br /> t <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH�� I <br /> INFO <br /> Z!. LF'a3 f <br /> + EH 13.24IRs=V.I/n51 LJ S,�J '0_0 <br /> EK 14.m <br />