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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)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> EXPIRES 1 YE R FROM DATE <br /> (Complete in Triplicate) <br /> 3 <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 conopliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and.Regulations of San <br /> Joaquin County Public Heallt�h�(Seivices. _ r <br /> y Job AddressCity Lot Size/Acreage <br /> (,+Ct�j✓ t cti Address <br /> Phone-_7 <br /> Owner's Nam AddI! ''//// .o <br /> Contractor "L-`� i/ Address <br /> ir�-•� License NN bZPhonel`tcio� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION LI but of Service Well ❑ <br /> Monitoring Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> ❑ <br /> I DISTANCE TO NEAREST:-SEPTIC TANK SEWER LINES DISPOSAL FLD� P'BOP. 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 /> t7 Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications <br /> 'V <br /> {'I Public FI Otherk C1 Delta Oep',th of Grout Seal Type of Grout <br /> 1-f Irrigation Approx.�th I�I Eastern Surface Seal installed by �1 <br /> Repair Work Done L3m <br /> - Type of Pup i2 <br /> State Work Done _15:!: <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth (� <br /> I \} <br /> TYPE OF SEP-TI.0 WORK:�NEW_INS7ALLATION-I-I—•REPAIR!-ADDM@tA -1--I-x-DESTRUC-TION I��fNo septic system permitted +f'public sewer is <br /> I available within 200 feet.l <br /> ` ~ <br /> ` Installation will serve: Residence— Commercial— Other I <br /> , � 1 <br /> .__.Number of living units: Number of bedrooms <br /> Water table depth " <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK. ❑ Type/Mfg -� { Capacity No. CompartmentsMethod of Disposal � <br /> PKG. TREATMENT PLT. ❑ <br /> ` Distance to nearest: Well Fb undation Property Line <br /> LEACHING LINE Cl No. & Length of lirias r-- Total length/size I" <br /> FILTER BED ❑ Distance to nearest: I Well.' Foundation Property Line <br /> �A <br /> SEEPAGE PITS I I Depth Size ' Number <br /> SUMPS Ll Distance to nearest: Well F,oundatiori Property Line i <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the wdrk,will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County I- <br /> f Home owner or licensed agent's signature certifies the foliowing�'I.certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in inch manner as to become subject to-workma6's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: II rinify-that.in_the 6rformance'of the work for whi{h this permit is issued, I shall employ persona subject to workman's compensa- <br /> tion laws of Csilfornia. �°" " r <br /> The applicant m st all for all require inspections., omplete,clraving own reverse side. <br /> Signed X "''Title: ---- Date: <br /> ( <br /> F DEPARTMENT USE ONLY 4 <br /> Application Accepted by Data Area t ` <br /> t <br /> Pit or Grout Inspection by <br /> Date I Final Inspection by`�^ Date <br /> z <br /> Additional Comments: <br /> 1 f <br /> s Applicant - Return all e6pies ;to: San Joaquin County Public Health <br /> ' Services, Environmental Health Permit/Services <br /> i 1601 E. Hazelton,Ave.,•.P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASA RECEIVED BY DATE PERMIT'NO. <br /> INFO, } �r <br /> a EH 13.24(REV.t/XSl 5 .�'� (/ 0, -A'_� <br /> E EH <br /> t <br />