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APPLICATION 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, STOCKTON, CA 95201 <br /> PE_IT EXPIRES 1 YEAR. FROM PATE MME <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 /> � � , G,IfgQf� City Lot Size/Acreage <br /> Job Address <br /> r <br /> wner's Name PIP/C& Address t^'+ Phone <br /> Ot� (� .•, ,�. - <br /> y r — U c� Address_on �O� � �� License No,.�Phone <br /> Contr3clor <br /> ^► TYPE OF WELL'/PUMP:"" r "-NEW WELL CD REPLACEMENT C DESTRUCTION ❑ �t't4onitoring Well <br /> i <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE Tb NEAREST:'SEPTIC TANK 'SEWER LINES" — DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS , <br /> Dia. of Weil Casing <br /> Ci Industrial t ❑ Open Bottom C7 Manteca Cie. of Well Excavation-------- <br /> C:' DomesiiclPrivate ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> C; Public to Other n Delta Depth of Grout Seal <br /> t `Type of Grout_ <br /> I i Irrigation, Approx.Depth t I Eastern Surface Seal Installed by <br /> Repair Work Done r_7 Type of Pump H.P. State Work Done <br /> -Wei 1 Destruction ❑ Well Diameter <br /> Sealing Material & Depth <br /> Depth Filler Material & pth <br /> t TYPE OF SEPTIC WORK:, NEW INSTALLATION I I REPAIRfADDITION DESTRUCTION I I (Noavasblerwt st m200 Perm <br /> fe`rt)ed if public sewer is <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: SG�` LOtrCirlL�P�� Water table depth <br /> f, <br /> SEPTfC TANK O Type/Mfg Capacity � No. Compartments <br /> PKG, TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> ^ <br /> LEACHING LINE tet'/No. & Length of lines �h :Total length/size _ , <br /> f <br /> FILTER BED 13 Distance to nearest: Well�1 Foundation;— Property Line b d <br /> i' <br /> I r SEEPAGE PITS I I Depth ,- —Size —� Id Number r <br /> t SUMPS (/"Distance to nearest: Well �' Foundation�.. Property Line — <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 <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 compenaa- <br /> tion laws of California." <br /> The applicant must tail for all re itedinspections. Complete drawing on reverse side. .11 tt �j <br /> Title: 5a�rj Date: <br /> Signed X L7 r <br /> . t ` <br /> OR T NT U5 ONLY <br /> Application Accepted by Date Ar <br /> ,. Date Final Inspection by;�iDate <br /> Pit or Grout Inspection by <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., P 0 Boz'2009, Stockton, CA 95201 <br /> I fEE gMOUNT DUE AMOUNT REMITTED CKs RECEIVED BY DATE PERMIT NO. <br /> l INFO 1� ( CASH p,� rr�� �-1t {^p _�ar� [ ,, <br /> j ♦ EH 13.E(REV.tiny 1 l..l. � �..! 3 . <br /> p.- `[ 4 k"W�YI <br />