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t <br /> I APPLICATION FOR PERMIT <br /> SAN J'OAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1501 P.OHAZELTON BOX 2009,1VE. , PHONE STOCKTON, CA0 —3420 <br /> 95201 <br /> t SIT E%PIRE9 1 YEAR FROM DATE ISgJTED <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 Servs. <br /> Job AddressCity Lot Size/Acreage <br /> C ' <br /> 3 , q_ <br /> Owner's Name � Vlhn' Address one <br /> Contractor Address <br /> Q� License o hl Phone <br /> TYPE OF WELL/PUMP; e (YEW WELL ❑ WELL__REPLACEMENT~❑_,DESTRUCTION C) Out of Service, Well Ci <br /> � _ of Service <br /> Well <br /> PUMP INSTALLATI SYSTEM REPAIR ❑ (fX& THER ng C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES' �— DISPOSAL FLD. PROP. LINE I <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE ! TYPE OF\WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C-I Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing <br /> F Domestic/Private 0 Gravel Pack C1 Tracy Type of Casing Specifications <br /> I'I Public {1 Other i F-1 Delta Depth of Grout Seal Type of Grout <br /> I I irrigation _Approx. Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ f Well Diameter Sealing Material & Depth <br /> Depth Filler Material& Depth,11: <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/A'DDITION 1 I -DES.TRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.l <br /> Installation will serve: Residence Y# Commercial Other <br /> Number of living units: -I-- Number drop J <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity � No. Compartments <br /> PKG. TREATMENT PLT:❑ Method of Di sal <br /> Distance to nearest: Well .F"OunciRi'�W-1 - p o.,perty'Line- <br /> LEACHING LINE No. & ia <br /> Length of lines ." - i <br /> g -•-n- -�.Total: ngth/size \ [[[ <br /> FILTER BED 0 Distance to nearest: Well FouridatioA---'"`� Pr'party Line `1 <br /> SEEPAGE PITS I I Depth Size <br /> Number ".'� . ,. <br /> SUMPS L1 Distance to nearest: Well ?_ Foundation r Property`Line <br /> DISPOSAL PONDS F ❑ Mh <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 cerify that in the,�rmance,of the work for which this-permit is issued, l shall not <br /> employ any person in such manner as to become subject to workmen's compensation laws of California," Contractrir'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, t shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant call for at!-re #" <br /> q inspecitons Complete drawing on reverse side. <br /> Signed '' Title: <br /> � Date: T <br /> DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date rea <br /> Pit or Grout Inspection by y �4 <br /> Final Inspection b Date -� <br /> . <br /> Additional Comments: Date <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED 8Y <br /> INFO CASH DATE PERMIT'NO. <br /> EH 3-24+ EH Z4.�(REV.t i k 61 r 1/ �4 V V /�! V P-, - <br />