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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> p11WIT EXPIRES 1 YEAR FROM DATA ISSUED <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 PuliealtTSvices. <br /> Job Address Qr1', /L` _ City��c� Lot Size/Acreage <br /> Owner's Name <br /> �� P <br /> Address Phone <br /> "Contractor llJJ...I -14 Address 3 L ��'4lcense No. Pfione- -� a <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Wel 1 <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER CI Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION __ AGRICULTURE WELL. -- OTHER.WELL .PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> F1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation' Dia. of Well Casing <br /> C.I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> i'1 Public C1 Other Cl Delta Depth of Grout Seal Type of Grout <br /> I I Irti{lation Approx. Depth ~l 1 Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P, State Work Done e <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION RUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.I <br /> Installation will serve: Residence`Commercial_ ther <br /> Number of living units: —,/— Number of edrooms <br /> Character of soil to a depth of 3 feet: _ _Water table depth l\ <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ } Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE C4 -Length of lines ot%length/size <br /> FILTER BED 0 Distance to nearest: Well �z Foundation �� Property Line <br /> SEEPAGE PITS I I Depth Size _ Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <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 4 "• <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permi4 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 /> ce ' ' s the following: "I certify that in the performance of the work for which this permit is issued, l shall employ persons subject to_arorkmen's compensa- <br /> ti . laws litornia," <br /> 7h plicant us 11 f r all re ti ns. C pl t dr ing on verse aid <br /> Signed tle: r,_ —-- Date: • <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by DateGl 46 — <br /> Area 1-5 <br /> Pit or Grout Inspection by Date Final Inspection byDate J�C��< <br /> �0-4 <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 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO /} r7 CASH <br /> + EH 13-24(rtEV.r/n5) y --}r�� ] VS <br /> EH 11.16 r 4� O� <br />