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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 0 BOR 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSPED <br /> (Complete in Triplicate) rr <br /> Application is hereby made.to San Joaquin County for a permit to construct end/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Begulations of San <br /> Joaquin County Public Health Services. <br /> Job Address �/ / �' City Lot Size/Acreage <br /> t � <br /> Owner's Name &1&:S_7Y?As e45A __ _ Address Phone OG30 <br /> t <br /> Contractor G y I +( Address P &S � License No.✓'Rr'1�5+7e Phoneme &-? •7z,7F <br /> TYPE OF WELL/PUMP: NEW WELL © WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION © SYSTEM REPAIR 0 OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK t 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 /> f--] Industrial ❑,Open Bottom' ❑ Manteca Dia. of Well Excavation Dia: of Well Casing <br /> [I Domestic/Private .: 0 Gravel Pack LJ Tracy Type of Casing Specifications <br /> FI Public 17 Other fl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation W _ _Approx._D"epth. I_I_Eastern Surface Soul installed by <br /> Repair Work Done L3 Type of Pump, - H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION r REPAIR/ADDITION 11 DESTRUCTION l I (No septic system permitted if public sewer is <br /> -available within 200 feet.) <br /> Installation will serve: Residence— Commercial-K Other <br /> Number of living units: t Number;of bedrooms f <br /> Character of soil to a depth of 3 feet: - -- - — Water table depth <br /> SEPTIC TANK ' Type/Mfg PILL. Ca IJ CA-r< CapacityX12&Z - No. Compartments <br /> PKG. TREATMENT.PLT, 0 Method of Disposal <br /> Distance to nearest: Well /410` Foundation /101 Property Line /a <br /> .. i <br /> LEACHING LINE �f No& Length of lines __-C- -_��a Total length/size <br /> FILTER BED 1-1/Distance to nearest: Well ���' Foundation Property Line la _ <br /> f � <br /> y SEEPAGE PITS I I Depth Size _ Number <br /> SUMPS, A S LI Distance to nearest: Well Foundation Property Line s <br /> DISPOSAL PONDS Ll a <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 anis 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, l 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 i <br /> certifies the fol#owing: "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 applicant must call for al required inspections. Complete drawing on reverse side. { <br /> Signed � Title: —g:4.. Date: <br /> f <br /> FI?A'RTMENT USE ONLY <br /> Application Accepted by C1. Data - Area <br /> Pit or Grout Inspection by Date 1 Final Inspection by Data <br /> Additional Comments: <br /> y <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 /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DA/TE PERMI�+Tj(N�O. <br /> a EH 13-24{REV.1 K 51 �� V() <br />