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APPLICATION FOR PERMIT <br /> SAN 30AQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 7 1601 E. HAZELTON AVE. ,T <br /> P O BOX 2009, PHONE <br /> CA095201-3420 <br /> EXP RES 1 YE R FROM DAT f <br /> (Complete ifn Triplicate) <br /> made to San'Ioaquin County for a permit to construct and/or <br /> instal62 and the Rules andwork eRegu]8tionsdof Sana <br /> Application is hereby Ordinance ' <br /> application is made in compliance with San Joaquin County <br /> Joaquin County Public Health Services. Lot Size/Acreage �y^� <br /> /© City <br /> Job Address �s � Phone <br /> r <br /> Address <br /> Owner's Name ' �� Phone !a <br /> f' License Na. <br /> i Address DESTRUCTION C1 Out of Service Well ❑ <br /> Contractor WELL REPLACEMENT ❑ Monitoring Well <br /> NEW WELL ❑ OTHER ❑ <br /> i TYPE OF WELLIPUMP: SYSTEM REPAIR ❑ <br /> PUMP INSTALLATION ❑ DISPOSAL FLD. PROP. LINE <br /> SEWER LINES �— -- PITSISUMPS <br /> DISTANCE TO NEAREST: SEPTIC TANK �--�------ AGRICULTURE WELL OTHER WELL�--- <br /> FOUNDATION <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing f <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications V <br /> Ll industrial Type of Casing L 1 <br /> Ea [] Tracy Domestic/Private ❑ Gravel Pack Type of Grout V <br /> I'1 Public Cl Other <br /> n Delta Depth of Grout Seal <br /> Surface Saul installed by <br /> 1 l Irrigation —.Approx. Depth t 1 Eastern H.P.of Pump State Work Done IN <br /> �--- <br /> Repair Work Done. L7 Type Sealing Material & Depth <br /> Welt Destruction ❑ Well Diameter Filler Material & Depth <br /> p <br /> available within 200 feet.) <br /> i . <br /> TYPE OF SEPTIC WORK: NEW111� INSTALLATION I i REPAiR�ADDITION l I DESTRUCTION 14 INCseptic system permitted if public sewer i <br /> epth <br /> Installation will serve: Residence Commercial/ Other�---� <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: Capacity �G o No. Compartments <br /> ' SEPTIC TANK {?� Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Foundation y Property Line <br /> Distance to nearest: Well { <br /> T \ <br /> IX q ,Ga-, Totallengthlsiza <br /> LEACHING LINE LNo. & Length of lines Foundation _ Property Line <br /> FILTER BED n Distance to nearest: Well ---- <br /> 41- <br /> Size Number <br /> SEEPAGE PITS 11 Depth Foundation— property Line <br /> SUMPS LI Distance to nearest: Well <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, a <br /> l 0 <br /> rules and regulations of the San Joaquin County following: 111 work for <br /> Home owner or licensed agent'stggn �re pme subject to workman'srtcompensation lawsoof Californiahe Contractor's <br /> rhuing or sub-contractinghis permit is signature <br /> Home <br /> employ any person in such man persons subject to workman's compensa <br /> f certifies the following:"I Certify that in the performance of the work for which this permit is issued, I shall employ <br /> tion laws of California." <br /> j The applicant m II for all requir d ins tions. Complete drawing on reverse side. _ Date: <br /> Title: <br /> signed X <br /> FOR DEPARTMENT USE ONLY �/ <br /> r Date a r /�} <br /> Application Accepted by Datg! <br /> Date --- Final Inspection by 4 <br /> Pit or Grout Inspe5 <br /> ction by ` � s' �"/ <br /> f Additional Comments: <br /> 4Public Health <br /> Applicant — Return all copies to: Se van ices , Enoaquin vironmmental Health Permit/Services <br /> t 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> CK RECEIVED BY DATE PERMIT'NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO ( <br /> . EM 13-24 ItiEv.I I n s) <br /> 7P r 7 6 �/o��j'� ,, ✓ <br /> EH 14.25 <br />