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APPLICATION FOR PERMIT- <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES t � <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCETON, CA 95201 APR 1 G 1991 <br /> PMWIT EXPIRES 1 YEAR FROM DATE ISS 1 <br /> (Complete in Triplicate) ENS"', HEAL,- <br /> vilIe CES <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the work h xte'ih flea ed. This <br /> application is made in compliance with San Joaquin County Ordinance No. 5119 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> CityS 4 Lot Size/Acreage <br /> kJob Address <br /> Ad ess a 3 Phone <br /> y Owner's Nam G <br /> Contractor �5 <br /> Il n Address t/ -License No. Phone <br /> i~�c <br /> TYPE OF WELL/PUMP: Nk:w WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ out of service Well ❑ <br /> PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Z� <br /> tdustriai ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing \ <br /> r I Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing � Specifications <br /> I'I Ptl6lic IIJ10gther F1 Delta Depth of Grout Seal Type of Grout �j <br /> 1 1 Irrioation t/s[_.Approx. Depth I I Eastern Surface Sedi installed by 1/ <br /> Repair Work Done U Type of Pump H.P. State Work Done _ <br /> Well Destruction O Well Diameter Sealing Material & Depth ' <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth V1� <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 ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby cenify 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 feguistions 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, 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 /> certifies the fotlowi "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 Cal' rni .' <br /> The applican ust all for all re inspe, ti s. Complete drawing oo verse side. �/ / <br /> I Signed X Title: `��`� � Date: ! ` �_ <br /> t <br /> Lf�l A A <br /> FOR DEPARTMENT USE ONLY r <br /> Application Accepted by <br /> Date Area ' -" <br /> Pit or Grout Inspection by Date Cr Z g r Final Inspection by Date 44_1 <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 CAS <br /> INFO K RECEIVED BY ATE � PERMIT N0. <br /> ��''7}p{ <br /> . EH 13-24 OLEv.r ins) ,0-0 t/ t`'V� r <br /> EH 14.26 <br />