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APPLICATION FOR PERMIT <br /> SAN J'OAQUIN COUNTY PUBLIC HEALTH SERVICESY w' MM Wall, <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZFLTON AVE. , PHONE (209)5468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 MAY 2 1991 <br /> f PERMIT EXPIRES 1 YEAR FROM DATE j;VV;R 1NA4ENTAL HEALTH ' <br /> (Complete in Triplicate) EUi iWIV ERVICES <br /> Application is hereby made to San! <br /> 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 blic Health S rvices. <br /> Job Address / L_- -'� . _ City ize/Acreage <br /> Owner's Na J ddress ! T Phone <br /> o r e s ���&icense No4gel Phone ¢J <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMf NT ❑ DESTRUCTION ❑ Out of Service Well Cl <br /> PUMP INSTALLATION 0 SYSTEM REPAI OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES //DISPOSAL FLD. PROP, LINE <br /> t <br /> - _.FOUNDATION- AGRICULTURE-WELL OTHER WELT PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM,AREA CONSTRUCTION SPECIFICATIONS ' <br /> 0 Industrial 0 Open Bottom ❑ Manteca \ Dia. of Well Excavation Dia. of Well Casing <br /> Be <br /> mestic/Private Ci Gravel Pack y ❑ Tracy Type of Casing Specifications ; <br /> / 11 Public 1-1 Other enNita �4; Depth of Grout Seal Type of Grout <br /> I I Irrigation �.Approx. Depth stern� . Surface Seal Installed by T` <br /> Repair Work Done ❑ Type of Pump �- �. H.P.O� State Work Don <br /> Well Destruction D Well Diameter f- Seal Fng Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is rl <br /> i <br /> „ +. '... -I ' available within 200 feet.) P r <br /> Installation will serve: Residence_.___.' Commercial_ Other � h� <br /> Number of living units: iNumber of bedrooms <br /> 1 f <br /> Character of soil to a depth of 3 fest: ! Water table depth <br /> SEPTIC TANK. ❑ Type/Nigr Capacity No. Compartments <br /> PKG. TREATMENT PLT. C3 r Method of Disposal 1 <br /> Dist nce to nearest: ,Well l ,Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED Ll Distance to nearest: Well Foundation Property Line <br /> Ile <br /> EEPAGE PITS 11 Depth f Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> `DI'SPOSAL 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 compensa- <br /> tion laws of California." ; <br /> The applican r t e i for 11 a uired ingpections, Complete drawing on rever side. <br /> , / <br /> Signed Title: Dataor <br /> r�1 <br /> r <br /> i <br /> _ FOR DEPARTMENT USE ONLY / <br /> Application Accepted by ;ftane:::� Date v Area <br /> Pit or Grout Inspection by ate Final inspection by_ ' ,• Date S 1 <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 Box 2009, Stockton, CA 95201 i <br /> II <br /> FEE C <br /> INFO AM��O��U''--�T DUE AMOUNT REMITTED /CASH RECEIVED BY DATE PERMIT'NO. 4 <br /> . EH17.3i1HEV.eins) Yr�„� <br /> EH 14•2e <br /> J <br />