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f <br /> + 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 2f <br /> TON, CA 95201 <br /> EXPIRR M D TE ED <br /> r <br /> (Compiplicate) <br /> Application is hereby trade to San Joaquin County for struct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin CoNo. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. r <br /> C� lJ� Lot Size/Acreage <br /> Job Address uity <br /> _.T � t <br /> Owner's Name Address Phone <br /> �Jr S dress License No. Phone <br /> Contractor _ <br /> TYPE Of WELL/PUMP: NEW WELL/ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> SYSTEM REPAIR ❑ OTHER © Monitoring Well i7 <br /> PUMP INSTALLAT <br /> IO <br /> N <br /> DISTANCE TO NEAREST~ SEPTIC TANK _zSEWER LINES DISPOSAL FLD. �`' PROP. LINE �L! <br /> FOUNDATION _Z ' AGRICULTURE WELL &HER WELL_gj:�ITS/SUMPS /lev <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ng <br /> n Industrial 1 ❑ Open Bottom ❑ Manteca .,.Dia. of Well Excavation_�7.r- Dia. of WeN CasiA <br /> Type Casing Specifications <br /> i'Domestic/Private Gravel Pack 0 Tracy yP g� <br /> I`I Public #:1 Other `� f1 Delta Depth of Grout Seai ��o <br /> Type of Grout S ` <br /> I I Irrigation Approxi Depth 11 Eastern Surface Seal Installed by_�A - <br /> Repair Work Done 0 Type of Pump �. H.P. — State Work Done-, <br /> Well Destruction ❑ Well Diameter <br /> Sealing Material & Depth f <br /> Filler Material'&'Depth -� <br /> i Depth-- �-- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION i I DESTRUCTION 1 I.INo septic system permitted if public sewer is �1 <br /> available within 200 feet.I <br /> Installation will serve:-Residence Commercial � Other <br /> Number of living units: Number of bedrooms r <br /> n Character of soil to a'depth of 3 feet: Water table depth z <br /> SEPTIC TANK, :f �' Type/Mfg: s Capacity No. Compartmentsf <br /> PKG. TREATMENT PLT., 1.' Method of Disposal �J <br /> * Distance to nearest: Well Foundation Property Line l <br /> &-Length of lines Total length/size <br /> LEACHING LINE C1 No. <br /> FILTER BED I , EI Distance to nearest: Well Foundation Property Line I <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ I, I <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, l 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 compensa- <br /> tion laws of California." <br /> The applicant requ�iions. mplete drawing an reverse side. <br /> Signed X Title: Date: <br /> 5/3 <br /> FOR DEPARTMENT US ONLY <br /> Nea <br /> Application Accepted byDate <br /> Pit or Grout Inspection by �te J 11 Final Inspection by Date <br /> 60 r ,•a 1 G rr s <br /> Additional Comments: ¢ _ - - -- ` <br /> Applicant -._Return all,copies.to: .San Joaquin County Public Heal <br /> h - ~` <br /> Services, Environmental Health Permit/Services <br /> �f 1601 E. Hazelton Ave., P O.Box 2009,�Stockton, CA 95201 <br /> FEE AMOUNT DUE AMp T REMITTED CKRECEIVED BY DATE PERMIT'NO. <br /> CASH <br /> INFO <br /> r EH 13-24(REV.tin 5) �yP _ _ �� -_ , ` '� � •lrl'� ���Q <br /> EH 1446 <br /> d <br />