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rttF7 <br /> APPLICATION FOR PERMIT V <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 p•0 BOX 2009�, STOCKTON, CA <br /> HAZELTON V095201- 3420 <br /> E%PIRES 1 YEAR FROM DATE ISSi3ED <br /> (Complete in Triplicate) <br /> vork <br /> in <br /> Application is hereby made,to SanJoaquinCounty for u teY�dinancet to nNo 549struct s do1862sand thetall e}3ules and Regulations dor Sane <br /> pp <br /> application is made in compliance with San Joaquin County Ordinance. <br /> No. <br /> County Public Health Services. <br /> �j,97111111NCity Lot Size/Acreage <br /> Job Address t! r "�� <br /> 't-S ��' Phone <br /> ddress <br /> Owner's Name � <br /> J )cense <br /> No.. Phon <br /> Contractor ddress <br /> WELL REPLACEMENT DESTRU TION Out of ervice Well ❑ <br /> NEW ELL ❑ Monitoring Well CJ <br /> E OF WELLlP P: ❑ OTHER ❑ <br /> T SYSTEM REPAIR <br /> PUMP INSTALLATION ❑ <br /> SEWER LINES -- DISPOSAL FLD. PROP, LINE <br /> DISTANCE TO NEA SEPTIC TANK �___ OTHER WELL ____ PITS/SUMPS <br /> FO .N AGRICULTURE WELL <br /> M AREA CONSTRUCTION SPECIFICATIONS t <br /> INTENDED USE TYPE OF WELL Dia, of Well Casing <br /> ❑ Open Bottom ❑ Manteca of Well Excavation . <br /> i�1 Industrial Specifications <br /> is Domestic!Private ❑ Gravel Pack ❑ Tracy Type of Casing <br /> Depth of Grout Seal Type of Grout <br /> I'I Public (] Other i 11 Delta ---- <br /> Approx. Depth I I Eastern Surface Seal Installed by <br /> I I tnigation , State Work bane <br /> Repair Work Done U Type of Pump H.P. s <br /> Sealing.material_&„Depth _ <br /> Well Destruction ❑ Weil Diameter --------- - Filler Material & Depth ` <br /> Depth <br /> 10 { septic system permitted if public sewer is <br /> f TYPE OF SEPTIC WORK: NEW INST L ATION I 1 , REPAIR/ADDITION it I Di a ilable within 200 feet,) <br /> t � <br /> Installation will serve: Residence ! Commercial_ Other— , ; x <br /> _ - ,t ' <br /> Number of living units: Number beciroorns t Water table depth <br /> Character of soil to a depth of 3 feet.: No. Compartments <br /> SEPTIC TANK 13 Type/Mfg Capacity--. , <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> k Distance to nearest: We Foundation Properly Line <br /> ( t <br /> 4 Total length/size <br /> LEACHING LINE ❑ No. & Length of line _ pro ert Line <br /> FILTER BED C1 Distance to near Wali Foundation - p y <br /> c.. <br /> _� <br /> SEEPAGE PITS 11 Depth Size Number f <br /> Fo dation Property Line <br /> SUMPS Ll Dis as,to nearest: Weil 4 <br /> DISPOSAL PONDS ❑ 4 <br /> 1 hereby certify that I have prepared this application and that the work will be do 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 rformance of the work for which this permit is issued, 1 shall not <br /> employ any person in such manner as to become subject to workman's compensation la of California," Contractor's hiring or sub-contracting signature <br /> certifies the fallowing: "I certify that in riormance of the work for which this permit is t ped, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applican ust r r qu ed ' s ctions. Co lets rawing on reverse side. r <br /> Title: Data: <br /> Signed { <br /> DEPARTMENT USE ONLY 1 <br /> r fea <br /> Application Accepted by Date <br /> Pit or Grout Inspection by Date 0 <br /> F' a1 llnspection by Date <br /> Additional Comments: „�� �ydp jy� 4—,V—bJ4S S <br /> Applicant ^ Return all aopiee to:- San oaquin ices, Envi otamentaliHealthtPermit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT REMITTED CK RECEIVED !3Y DATE PERMIT NO. <br /> AMOUNT DUE CASH <br /> f0► <br /> 77f315-00 � � o q9c> <br /> ♦ EN 1324 1 REI.1/1451 INFO <br /> EH'14.26 <br />