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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 3'{� <br /> k ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOR 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DAIN 155UED r "' <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 d <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 Servi s. <br /> l <br /> Job Address City Lot Size/Acreage <br /> ` Owner's Name ress Phone <br /> .I <br /> Ctintracta ense N <br /> ro.rPhone ✓ <br /> �. TYPE Of W LL/PUMP:- NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER © Monitoring Well ❑ <br /> F a, <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 WECL'p PROSLEM,AREA CONSTRUCTION SPECIFICATIONS " <br /> In Industrial : ❑ Open Bottom - ❑ Manteca Dia, of Well Excavation ! Dia. of Well Casing <br /> C.] DomestielPrivate ❑ Gravel Pack C] Tracy Type of Casing Specifications <br /> I'1'Public I Cl Other f j ' C1 Delta Depth of Grout Seal Type of Grout <br /> 1 I Irrigation _=Approx. Depth f I Eastern Surface Seal Installed by <br /> Repair Work Done I C Type of Pump I H.P. State Work Donely <br /> _ <br /> Well Destruction t ❑ Well Diameter t Sealing Material & Depth <br /> Depth + Filler Materia Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ! I REPAIR/ADDITION ! DESTRUCTION I I (No septic system permitted if public sewer is <br /> 4 available within 200 fee_tJ <br /> Installation will serve: Residence�' Commercial Other x <br /> Number of living units:__L Number of bedrooms r ` <br /> f Character of soil to a depth of 3 feet: ; Water table depth <br /> SEPTIC TANK y ❑ Type/Mfg Capacity No, Compartments <br /> ft 4V <br /> I f PKG. TREATMENT PLT. Cl � _ / Method of Disposal � <br /> Distance to nearest: Well�_ Foundation 19 Property Line <br /> LEACHING LINECl' No. & Length of lines I E Total length/size <br /> f FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS.-A., 11 Depth i _ NumberIL <br /> ~ <br /> UMP Ll Distance to nearest: Well Foundation dation rProperty Line _,, �' <br /> ID SPOSAL PONDS ❑ f ~' <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 ficensed agent's signature certifies the following: 'Tcertify that in the performance of the work for which this permit is issued, I shall not <br /> r;. 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 /> E certifies the following: "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 /> tion laws of California." <br /> The applicant t for..4 requirespe tions. Co 6 awing n re eLliiL.,daA ! <br /> r <br /> cam" Signed le: _ _ ° Date: <br /> � <br /> �FQR DEP MENT USE ONLYApplication Accepted by _ b 1 f ! <br /> Date^ 1 <br /> 'ti1Me[s��m/�--'- Area <br /> Pit or Grout Inspection by Date I Final In y� v' a Dat <br /> Additional Comments: <br /> i <br /> Applicant - Retuall copies to: San Joaquin County Public Health ^��ce r r s re <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave.% P 0 Box 2009, Stockton, CA 95201 ,Jr� <br /> FEE <br /> f <br /> lMPO AMOUNT DUE AMOUNT REMITTED CASH i RECEIVED BY DATE PERMIT N0. <br /> . EH 13.24rAEV.t/A51 �� p ~ F , <br /> EH 14.2e r (_— /v <br />