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APPLICATION FOR PERMIT <br /> r <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES i <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)465-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> EMIT 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 Sery es. <br /> Job Address 1,316o r Cit Lot Size/Acreage <br /> Owner's Nam Address Phone <br /> Contract Address License-No Z z Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT E7 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK r SEWER LINES DISPOSAL FLD. PROP. LINE <br /> fR� �r-- FOUNDATION =�` ��AGRICULTURE-WELL�•�' OTHER'WELL <br /> t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS # <br /> L7 Industrial © Open Bottom 0 Manteca Dia. of Well Excavation Dia, of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack El Tracy Type of Casing— Specifications <br /> FI Public f:7 Other I1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —.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 D Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION E57RUC7iON I k INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Com rcial ✓ O;her <br /> Number of living units: er Numbof b rooms r Gt,c.C,crn <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE- 0 No. &-Length-of-lines--. -­---—Total-length/size - <br /> 4 FILTERISED- Cl Distance to nearest: Well Foundation Property Line <br /> ' P + <br /> SEEPAGE PITS�' �s Depth Size a Number ' <br /> I <br /> SUMPS le <br /> L! Distance to nearest: Weltfoundation / Property Line <br /> ' . <br /> DISPOSACPONDS' p Ar- <br /> I•ha by 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. _' f / <br /> Home owner or licensed ' <br /> a ants signature certifies the following:9 g g: "I certify that in ttie•performance of the work for which this permit is issued, l shall not <br /> employ any person in such manner as to become subject to workman's compensation law§'of•California." Contractors 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 mut Il for allWirspeclions. Complete drawing on reverse, id , <br /> t <br /> Signed X a Title: Date: go <br /> r / FOR DEPARTMENT USE ONLY <br /> Application Acte Q-by Date Area <br /> FPit r Grout Inspection by r r 1 Date / ina! Inspection by Date <br /> i . <br /> t ; Additional Comment ' -P-5Lj La,.,Q 1 n -S f <br /> Applicant - Return all copies to: Sea,Joequin County Public Health <br /> !; Services, Environmental Health Permit/Services <br /> t 1601 E.*Haaelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> CK it <br /> FEE <br /> 4 - <br /> INFO AMOUNT DUE AMOUNT.REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> EH13-24 fREV.r i 1151 <br /> EH 114-26 r "/-1Z7/ <br />