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APPLICATION FOR PERMIT <br /> -.mom . .. <br /> j SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)46$--3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> MIT EXPIRES 1 YEAR FR M DATE ED <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 Joaquinunty Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. 4 <br /> Job Address A, City u Lot Size/Acreage'_ <br /> Owner's Name �� �- Address Phone <br /> Contractor___AL Address License N <br /> Phone <br /> k TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT LJDESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ 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 /> INTENDED USE­---TYPE-OF WELL' —PROBLEM-AREA'—CONSTRUCTION-SPECIFICATIONS— <br /> C] Industrial ❑ Open Bottom ❑ Manteca Dia. of Wei! Excavation <br /> Dia. of Well Casing <br /> [D Domestic/Private Cl Gravel Pack 117 Tracy Type of Casing S <br /> V1 Public'"'v „ (.1 Other + ❑ pelta Specifications <br /> I i Irriga[ion _ <br /> Depth of Grout Seal Type of Grout <br /> A <br /> —_. pprox. Depth ('I Eastern Surface Seal Installed by <br /> Repair Work pone 0 Type of Pump H.P. <br /> Well Destruction ❑ Wel! Diameter Sealing Material & Depth State Work Done_ <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ! I DESTRUCTION f 1 {No septic system permiipt',blic ifwer iss*,- <br /> available within 200 feet0 <br /> Installation will serve.Residence Commercial��-pther'c` �^ ;4 ." <br /> 4L. i <br /> Number of living units: � Number of bedroomsCharacter of soil to a depth of 3 feet:SEPTIC TANK. Water table depth❑ Type/Mig No. CompartmentsPKG. TREATMENT'PLT. El ` 4' . s .s _. Method of DiDistance to nearest: Well' sposast ��Foundation &�. ,Property LinaLEACHING LINE � No.4& Length of lines-FILTER BED Tbtal length/sizery { <br /> ❑ `Distance-to nearest: Well 7ZJ�'T Foundation r7�� b I <br /> .-�.LProperty Line <br /> SEEPAGE PITS I 1 .'Depth QST -Size. <br /> SUMPS Number <br /> Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordi <br /> rules and regulations of the San Joaquin County nances, state laws, and <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the parforvimance 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 following: "I certify that in the performance of the work for which this permit is issued, I shallemploypersons subject'to workman's cOmpensa- <br /> tion laws of California." <br /> The applicant must call fo II requi d inspections. Complete drawing on reverse side, <br /> Signed '`+ _ <br /> Title: '' Date: <br /> FOR 17EPARTMENT USE-0 <br /> Aky <br /> :Application Accepted by 4 Date <br /> fJ Area ZL <br /> Pit or Grout Inspection by Date <br /> ' --�� Final Inspection by Date <br /> Additional Comments: i <br /> Applicant •- Return Cu 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 /> 3 ' <br /> ,.... FEE �.- <br /> INFO AMOUNT Dt?E _,. . -• 'CK <br /> AMOUNT REMITTED CASH, RECEIVED BY DATE I <br /> - PERMIT'N0. <br /> + EH 13-211REV. <br /> i <br /> EH i42e - .-•• �^il <br />