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APPLICATION. FOR PERMIT <br /> f SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> t ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> ` P O BOX 2009, STOCKTON, CA 95201 <br /> fiP IT MIRES 1 YEAR FROM =R ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to S 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 he ulea and Regulations of San <br /> j Joaquin County Public Health ,9ervicea. <br /> II <br /> Job Address City Lot i ze/Acreage <br /> i MOwne'r:srN�ame- !` <br /> Address y,L�� l`' .. Phone <br /> nA <br /> !, <br /> u �� .rte + Address_ �lG 1 173 Z�(r <br /> Cantracto s_ License No.� Phone 3el-�-SIS',, <br /> jAG �TY-PE,OF_WELL,1PUMP:% f1;&'/,•/— NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCT10N�0 Out of Service Well ❑ <br /> t y PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ ti3J{� jc;OTHER:.❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TAM( SEWER-LINES -_-- __�pISPOSAL FLD. - PROP:LINE <br /> W' r1 <br /> FOUNDATION AGRIC►1L7URE-WELL OTHER WELL PITS/SUMPS <br /> iINTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION-SPECIFICATIONS <br /> ), j. <br /> C] tndustriai ❑ Open Bottom ❑ Manteca Di&-pf Well Excavatibri Dia. of Well Casing <br /> F1 Domestic/Private ❑Gravel Pack ❑ Tracy Type of Casing Specifications s <br /> I'; Public Delta � • " <br /> Typ�'ot Gr <br /> out <br /> I I Irrigation ~Approx. Depih'. .I I Eastern Surface Seal Ihstitled by <br /> Repair Work Done U Type of Pump H P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material1 Depth <br /> Depth Filler Material A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION DESTRUCTION I I INo septic system permitted it public sewer is <br /> All available-within 200 feet.) <br /> Installation will serve: Residence Commercial_ that <br /> r _ <br /> Number of living units: � Number of b o ms -. <br /> Character of Sall to a depth of 3 feet: <br /> Water table depth k <br /> SEPTIC TANK Type/Mfg Capacity rNo, Compartments 1 <br /> PKG. TREATMENT PLT. ❑ t <br /> = 'Method of Disposal <br /> Disiance to nearest: Well <br /> = Foundation Property Line s <br /> J <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Propeity line <br /> i 4- <br /> SEEPAGE PITS 11 Depth l Size- Number <br /> SUMPS Lf Distance to+nearest: Well Foundation Property Line- <br /> DISPOSAL PONDS I7 I <br /> I hereby certify that I have prepared this application and that the work wilt be done in accordance with,San Joaquin county ordinances, state laws, and r <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, I shall not <br /> employ any person in such,manner as to-become subject to workman's compensation lavyi_of California, Contractof;hiring or_sub contracting-signature__ <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, t shall employ persona subject to workman's compensre l <br /> tion laws of California." <br /> The applicant t call forM <br /> inspections. C—omplete drawing`o reverse sid ' ' �jn <br /> Signed X - �Z` V - Title: .� - - - —._...ate: — - (C-/ <br /> Date: <br /> _ �� FOR DEPARTMENT USE ONLY <br /> Application Accepted by 2_!"fie Date r Lia Area _2-- <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: $au Joaquin County Public Health <br /> Services, Environmental Health Permit/Services ON <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 _l <br /> FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED aY DATE PERMIT NO. <br /> 40 <br /> INFO CASH <br /> + EFs13-24fAfV.+insr <br /> EH <br /> 11-20 'l/ <br />