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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 BOX 2009, STOCKTON, CA 95201 <br /> � . XPIRES 1 YEAR FR M DAT 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 Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> I <br /> City Lot Size/Acreage <br /> Job Address <br /> i� <br /> �y�` f[, � Address Phone <br /> Owner's Name <br /> f ! €« y -_ = License No: phone - _ <br /> ""'"'" Contractor '" "Aiidii ss�"' <br /> Well U <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out or service <br /> Monitoring Well <br /> PUMP INSTALLATION O SYSTEM REPAIR © OTHER ❑ <br /> } DISPOSAL FLD, PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> rFOUNDATION-- -- -- AGRICUL-TURE.WELL-=�OTHER.WELL. _P_ITSJ.SUM_PS--_ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I <br /> f7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Welt Excavation Dia. of Wel! Casing <br /> ns <br /> E]7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing t Typcilic Grout t Type of Grout <br /> I'1 Public I-1 Other F I n Delta Depth of Grout Seal <br /> I I Irrigation Apprdxl. Depth I I Eastern Surface Seul­lnstalled <br /> H.P. State Work W <br /> Repair Work Done L7 Type of Pump ial t <br /> Well Destruction ❑ Well Diameter Sealing r <br /> Depth <br /> j Fi ler I8e ' <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION l PAIR/ADDITIO I I OESTRUCTIO I 1 N jq�y�' Qt{ ted it public sewer is <br /> 4 Permit may�a���tJdilfli iced <br /> Installation will serve: Rest encs Lommercial Other eing com0eted or insp <br /> Number of livingunits; ! Number of be roomsWpa{+h J)IVis`on <br /> fCharacter of so to a depth of 3 feet: t Elio, t V19a"4er table depth <br /> SEPTIC TANK. © Type/Mfg 1_� -..Capacity-- - - _NoCompartments. <br /> PKG. TREATMENT PLT. C) / Method of Di <br /> sposa <br /> Distance to nearest: Well FIoundation Property Line <br /> L G <br /> LEACHING LINE L9—No. & Length of lines y I Tot I length/size <br /> FILTER BED Cl Distanceto nearest: Well •�/. Foundations Property Line <br /> SEEPAGE PITS I I Depth I Size ? Number <br /> r , � <br /> SUMPS istanee to nearest: Welt Foundation Property Line <br /> DISPOSAL PONDS ❑ 1 <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 t <br /> Home owner or licensed agent's signature cenifies 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 following; "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's eompensa- <br /> t California." ! <br /> r The bcant call or all red i ctio s. o to drawing_a verse s' e. <br /> �r <br /> Date: -- <br /> Signe <br /> F DEPARTMENT USE ONLY , p, <br /> a Application Accepted by Date by l Area ` 5 <br /> Pit or Grout inspection by Date _ Final Inspection by Date <br /> t , Additional Comments: <br /> r ? � <br /> Applicant - Return all copies to: San Joaquin County Public Health '€ <br /> ServiceB,.Enviroamental Health Permit/Services <br /> k 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> CK 11 €€ 44 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH F f RECEIVED BY DATE PERMIT N0. <br /> INFO 4 <br /> + EH 13.24(REV.1/N 51O ..Co '�l J <br /> 1 <br /> EH sz-28 1 <br />