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APPLICATION FOR PERMIT <br /> r <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICERECE Vin IVE <br /> ENVIRONMENTAL HEALTH DIVISION S�L 2 � �s9� <br /> 1601 E. <br /> HAZELTON <br /> (209)468-3420 , <br /> J O ENVIRONMENTAL HEALTH <br /> P-RJ[i T�xpl ES 1 VIVAP FROII AAT- Issir'IM pERMVSERVICES <br /> (Complete in Triplicate) <br /> hereby made to San Joaquin County for a permit to construct and/or install the work herein described. ThiSen <br /> tion <br /> application is hs <br /> Application is ere in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regula <br /> Joaquin County Public Health Services. <br /> "A119120t Size/Acreage <br /> Job Addressr� � � I <br /> V l rA J f <br /> Phone <br /> ,Address <br /> Owner's No ) r / <br /> / cense iro / Phon <br /> lb W, e <br /> d ass <br /> c'/COI {actor WELL REPLACEME T (-'i DESTRUCTION LU Out of Service Well n <br /> TYPE OF WELL!PUMP: NEW WELL ❑ OTHER ❑ Monitoring Well GI <br /> PUMP INSTALLATIO SYSTEM REPAIR 3t <br /> DISPOSAL FLDPROP. LINE 0 i <br /> SEWER LINES PITS/SUMPS. <br /> FOUNDATION <br /> DISTANCE TO NEAREST; SEPTIC TANK _— --- AGRICULTURE WELL OTHER WELL <br /> _ �� <br /> INTENDED USE TYPE OF WELL PROBL, EM'AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> ( Industrial ❑ Open Bottom [.1 Manteca Dia. of Well Excavation Specifications <br /> �d�omestic/Private ❑ Gravel Pack LJ Tracy Type of Casing ------ <br /> Typ <br /> ;•l Other 1­1T Delta Depth of Grout Seale of Grout <br /> r � <br /> '1 Public I S dace Soul,lnstalled by /�'7IS <br /> I I Initiation '__ Approx. Dep h Eastern f <br /> H.P. i f et r on <br /> Repair Work Done U Type of Pump & Depth O <br /> // Sealing Material. <br /> Well Destruction ❑ Well Diame ` <br /> Depth Piller Material &•Depth <br /> 1 I REPAIR/ADDITION I DESTRUCTION I I INo septic system permitted if public sewer is <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION <br /> available within 200 feet.l <br /> 1 r <br /> ` Installation will serve: Residence • ' Commercial Other; <br /> li Number of bedrooms <br /> Number of living units: Water table depth Q <br /> Chsracter of soil to a depth-of 3 feet:- ` <br /> Capacity i No. Compartments <br /> SEPTIC TANK i O Type/Mt _, _r �-� Method of Disposal <br /> ` PKG. TREATMENT PLT: ❑ + ` R L <br /> Foundation Property line <br /> Distance to nearest: Well <br /> - . a__ *+.' Total length/.size <br /> LEACHING LINE Ll N..o. & Length of lines w --- <br /> rCl pistance'to nearest: Well _ foundation . Prop'e Line <br /> FILTER BED I s <br /> I <br /> -L-.-Size <br /> _ Number • <br /> SEEPAGE PITS 11 i Depth ` <br /> " -F3unGatioh' Property Line <br /> SUMPS la F Distance to nearest: Well 11. <br /> DISPOSAL PONOS ❑ y <br /> F I hereby certify that I have prepared this application end-that the-work will be done in accordance with Sart Joaquin county ordinances, state Laws, and <br /> f rules and regulations of the San Joaquin County: (� <br /> Homeowner or licensed agent's signature certifies the following: '•I certify that in the perlormance of the work for which this permit is issued, t signature <br /> shall not f ` <br /> employ any person in such manner as to become subject <br /> the work('rano cpehss permitation laws a issuedof '/shall smployapersons rlsubject to workng of man's gcompensa- <br /> 1 ?�certifig�the following: "I certify that in the pe <br /> hon laws of California," <br /> 'The applica t call or r wired Inspec�tio <br /> ns. Complete drawing on rev 6ide.�• <br /> b�✓ Till Date: <br /> �i Sig d <br /> I FOE USE ONLY l <br /> i <br /> Data0- Area <br /> Application Accepted by 4 r" Z ZK rl/ <br /> I Final Inspection by Date <br /> Pit or Grout Inspection by t Date�-- <br /> ` Additional Comments: <br /> aquiApplicant - Return all copiers to: Sen Services, Eavi otomentaliHealthtPermit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> CK a RECEIVED By DATE PERMIT NO. <br /> IEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> . EM 11"24 IREV.rrh <br /> EH A-26 <br />