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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 O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR- FROM DATE-- ISSUED <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. y�7�y(�'�q <br /> Job Address � City <br /> 1 ft Lot Size/Acreage <br /> Owner's Name Address my� Phone <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR El OTHER ❑ Monitoring Well 0 <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 /> Cl industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'l Public 1-1 Other Cl Delta Depth of Grout Seal Type of Grout <br /> I I Ifrigation _.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P, State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth y <br /> Depth Filler Material & Depth pl'! <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION f REPAIR/ADDITION I I DESTRUCTION ( I INo septic system permitted if public Sewer is 3:7 <br /> available within 20(}feet.l � <br /> Installation will serve: Residence ecommercial Other <br /> Number of living units: --2-- Number of bedroomsY, <br /> Character of soil to a depth of 3 feet: ' <br /> A- h 0 La �rt Water table depth � i/1 <br /> SEPTIC TANK LR�Type/Mfg ckL- -04'1 G C_5-r-'0- Capacity 1100 No. Compartments 2. <br /> PKG. TREATMENT PLT. C) j Method of Dispo?al <br /> Distance to nearest: Well t 00 'ft• Foundation l Property Line � <br /> LEACHING LINE fad No. & Length of lines y " Z. 00 Total length/size <br /> FILTER BED 1-1 Distance to nearest: Well 0 Foundation j Property Line t�� <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation . Property Line f� <br /> DISPOSAL PONDS 0 (Sv <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 <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 workmen'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 compensa- <br /> tion laws of California." <br /> The applicant m st Fall for all r uired inspection Com late drawing on reverse side. <br /> Signe Title: Date: _,_ 7�L <br /> FPeDEPAJffMENT.USE ONLY ����'' <br /> Application Accepted by Date <br /> Area !P fes_ <br /> Pit or Grout Inspection by Date Final Inspection by Date . <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Ii Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CICK RECEIVED BY DATE PERMIT.NO. <br /> INFO p / <br /> . EH A-2A(REV,rixSY <br /> EH it �f3743 —PO �D t7 02 <br /> -26 <br />