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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH <br /> DIVISION 4 8- 420 <br /> 1601 E HAZELTON AVE. , <br /> P O BOR 2009, STOCKTON, CA 95201 <br /> EA I <br /> Egp <br /> RES11-111 YEAR FROM DATE ; <br /> (Complete in Triplicate) ribea <br /> permit to construct and/or install the work herein dlationedof Sans <br /> Application is hereby tnade,to San Joaquin County for a pe <br /> application is einHcompliance <br /> withSan Joaquin Count Ordinance No. 5 9 and ]862 and the Rules and Regulations <br /> Joaquin County public City L Lot Size/Acreage <br /> Job Address phone <br /> f Address i <br /> Owner's Name ' ' <br /> 3�D LJ License No�a=�•--Phone <br /> Address DESTRUCTION ❑ put of Service Well ❑ <br /> Contractor SWELL REPLACEMENT Monitoring Well <br /> TYPE 4F WELLlPUMP NEW WELL ❑�- �.. OTHER ❑ <br /> SYSTEM REPAIR ❑ <br /> PUMP INSTALLATION ❑ DISPOSAL FLD. PROP. LINE <br /> SEWER LINES P1TSISUMPS <br /> DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER_WELL <br /> -- <br /> fFOUNDATION ��--- <br />�. TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION Dia of Well Casing <br /> INTENDED USE <br /> ❑ Open Bottom 0 Manteca Dia. of Well Excavation Specifications— <br /> fn Industrial r Type of Casing <br /> Ca Domestic/Private ; ❑ Gravel Pack ❑ Tracy• Type of Grout O <br /> i <br /> 1-1 Other <br /> R Delta'" _D,epth of Grout Seal <br /> I'1 Public <br /> Surface Seal Installed by <br /> r i I Irrigation , ._._.Approx. <br /> Depth t 1 Eastern State Work Done <br /> �----- <br /> Repair Work Done L7 TYPa of Pump Sealing' Material & Depth ' <br /> Well Destruction ❑` Well Diameter i <br /> Filler Material 15 Depth <br /> Depth <br /> + TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIWADDITION I i, DESTRUCTION 4 I availablerwthin 200 ieee;I d ;f publicsewer is <br /> Installation will serve: Residence__��Commercial her --�— a <br /> Number of bCL s Water table depth <br /> Number of living units: 4— <br /> Character of soil to a depth of 3 fast: Capacity— No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg! Method of Disposal <br /> , <br /> PKG. TREATMENT PLT. ❑ a �� � �y'� � <br /> Foundation 1d-�— Property Line <br /> r Distance to nearest: Well r <br /> Tota Iength/size <br /> LEACHING INE (fYOo. $ Length of lines Foundation '� Property Line <br /> FILTER SED ❑ Distance to nearest: Weil----_--} <br /> _....�? <br /> Size Nurr�bar <br /> SEEPAGE PITS 4.1 epth —T�� D Property Line <br /> ell Foundation <br /> SUMPS LI Distance:to nearest: W <br /> DISPOSAL PONDS ❑ ' ' <br /> I harsh certify that I have prepared this application and that the work will be done +n accordance with San Joaquin county ordinances, state laws, and <br /> y <br /> rules and regulations of the San Joaquin County following: „ work for <br /> shall not <br /> Home owner or licensed agent's sigas torbecam become workman'srtcompensation lawsoof California." Contract tr s'hirng op sub-contracting ermit is issued, lsignature <br /> employ any person in such me <br /> e of the work for which this permit is issued, I shall employ parsons subject to workman's compens - <br /> certifies the fallowing: "I certify that in the performanc <br /> tion a of Californi <br /> Cmpiete drawingell <br /> qns ons.The applica on arse sid pate: r� <br /> Title: _ <br /> Signed <br /> FO DEPARTMENT USE ONLY <br /> Data. - <br /> 3� Area <br /> Application Acceptad by Final InspecLL tion by <br /> ' Gas Data <br /> it r Grout inspection by <br /> ate Z F <br /> {}dd tiona'>Comments: <br /> Applicant — Return all copies to: San ioaaquinYf otnmetbelliHe�lthtPermitJServicea <br /> 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 z <br /> IQV1,3 Q <br /> EH 13-24(REV.S/BSI r <br /> EH tb28 <br />