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4 APPL I CAT I OSI FOR PERMIT 50 ` <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 1 <br /> ENVIRONMENTAL HEALTH DIVISION � <br /> 1601 E. HAZELTON AVE. , PHONE (209)463-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> EXPIRES 1 YEAR FR M DA E ED <br /> (Complete in Triplicate) <br /> for a permit to construct and/or install the vork herein described. This <br /> Application is hereby made to San Joaquin County <br /> Ordinance No. 549 and 1862 and the Rules and Regulations of Ban <br /> application is made in compliance vith San Joaquin county <br /> Joaquin County Public Health Ser ces. <br /> City Lot Size/Acreag� <br /> Job Address <br /> Address Phone <br /> Owner's Name 3 <br /> Address <br /> _. <br /> License No. `�` Pbone �� �✓ <br /> Contractor. �r-— <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION Ll Out m Service Well <br /> onitoring Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ M <br /> DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i <br /> C] Industrial (D Open Bottom fa Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> Type of Casing Specifications <br /> (:1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Grout <br /> I'1 Public C] Other 11 Delta Depth of Grout Seal , <br /> I I Irrigation _,Approx. Depth I I Eastern Surface Seal Installed by <br /> J <br /> H.P. State Work Done _ <br /> Repair Work Done C7 Type of Pump t+iaterial b Depth " <br /> Sealing i <br /> Well Destruction ❑ Well Diameter FillerkMaterial i Depth <br /> f Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 'REPAIRlADDITION I�/DESTRUCTION l I availableic system within 200 feet-1rted if public sewer is �e <br /> Installation will serve: Residence Commercial_,..Other - <br /> Number of living units: _L_ Number of b drooms le I}�.�.Jit <br /> Water table depth <br /> i Character of soil to a depth of 3 feet: <br /> F SEPTIC TANK. I�Type/Mfg C Capacity t No. Compartments <br /> PKG. TREATMENT PLT.Cl t L►Y� e— Method of Disposal <br /> 1 - <br /> Distance to nearest: Well_� Foundations Property line Lf ' '.+g4 <br /> LEACHING LINE L4-'No. & Length of lines 10_! Total length size <br /> P <br /> Foundation <br /> Pr( <br /> perty Line <br /> FILTER BED ❑ Distance to nearest: Well�f , <br /> f *,. IG' Depth s- f �� Number <br /> — :r, .: <br /> ?5EEPAGE'PITS <br /> Size r <br /> I <br /> 'SUMPS 'Cl - Distance to nearest: Wel! r.��- -- Foundation�,°�f property Line 1�/��y�� �- <br /> ISPOSAL PONDS 1�1 ❑ = "' <br /> I hereby certify that I have prepared this-application.and-that the work will be done in accordance with San Joaquin county or <br /> finances, state laws, and <br /> j rules and regulations of the San Joaquin County <br /> l 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, I shall not <br /> E employ any person in such manner as to become subjeci to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> cartifies the following: "I certify that in the performance,of the work.for which this permit is issued, I shall employ pers6ns subject to workman's compansa- <br /> tion laws of California." } <br /> The applica t must ca 11 for all eq red inspections. Complete drawing on reverse side. <br /> �/J JI.G/.t,•L Date: <br /> Signed X Title: <br /> R DEPARTMENT USE ONLY <br /> Date Area <br /> 6pplication Accepted by <br /> Pito rout Inspection b , Date r���' Final Inspection b Date <br /> fAdditional Comments: <br /> i Applicant ^ Return all copies to: San Joaquin County Public Health <br /> Services,•Environmental Health Permit/Services <br /> I 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> ` !RE <br /> AMOmu.5! <br /> CRECENEC) BYPERMIT'NO. <br /> EH 13-24 iREV.t Hyl <br /> EH 14-26 <br />