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3 <br /> APPI;ICATION 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, STOCKTONIf CA 95201 <br /> EXPIRES 1 YEAR FROM DATE IS9UED <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 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. J <br /> Job Address ^n--_ City hot Size/Acreage <br /> Owner's NameO Ad ss Phone <br /> ContsactcSFZ Ce �Ld_rn/95 -Address icense fVo. �_Phone <br /> TYPE OF WELL/PUMPi NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK 0 Z>' SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C7 Industrial f Open Bottom ❑ Manteca Dia. of Well Excavation �r Dia. of Well Casing T <br /> omestic/Private Cl Gravel Pack C7 Tracy Type of Casing_ <br /> Specifications L <br /> I"I Public Cl Other 11 Delta Depth of Grout Seal 6.` Type al Grout <br /> . <br /> I i Irrigation —Approx. Depth <br /> , 1 ; Eastern Surface Seal Installed by <br /> Repair Work Done L7 Type of Pump � H.P. State Work Done <br /> Well Destruction ❑ Well Diameter <br /> Sealing Material Depth x • <br /> r Depth Filler Material b Depth <br /> j TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is <br /> } available within 200 feet,) <br /> Irtstallation will serve: Residence�" Commercial— Other v <br /> S, <br /> Number of living units:. Number of bedrooms <br /> Charactet of soil to a depth of 3 feet: 5 Water table depth <br /> SEPTIC TANK ❑ Type/Mfg r Capacity t No. Compartments <br /> ! Method of Disposal <br /> PKG. TREATMENT PLT. Cl � s� � _� <br /> Distance to nearest: Well " Foundation Property Line <br /> LEACHING LINE C1 No. & Length of lines Total length/size <br /> t <br /> FILTER BED CI Distance to nearest: Welt Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number f f <br /> SUMPS LI Distance to nearest: Well Foundation Property lane <br /> DISPOSAL PONDS ❑ <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 I <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, 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 persons subject to workman's compensa <br /> tion laws of California." <br /> The applicant must cif to I quired inspections. Complete drawing on reverse side, <br /> Signed X s c ._ Title: Date: -`� <br /> a k <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date �'y�- Area <br /> ! Lay <br /> f <br /> Pit or Gr t Inspection by Date"L�.(, r Final Inspection by at <br /> t <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., 2009, Stockton, CA 95201 <br /> FEE AMOUNT <br /> AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMiT'NO. <br /> f INFO <br /> EH 13-21 IftEV.t x 51 W j 3 r 3 �-° .a <br /> EH 341b <br />