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APPLICATION FOR.-PERMIT
<br /> SAN JOAQUIN COUNTY PUBLIC HEA.LTH. SERVICES
<br /> 11 ENVIRONMENTAL HEALTH DIVISION
<br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420
<br /> P 0 SOX 2009, STOCKTON, CA 95201
<br /> pMWIT EMIRTS 1 YEAR FROM DAT & '
<br /> (Complete in Triplicate)
<br /> i
<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 /> oegr City Lot Size/Acreage
<br /> Job Address
<br /> Address per'^ Phone
<br /> Owner's Name _a
<br /> _
<br /> p `?0,,.. ,1f . ft!l, '"`��icense No.�� -Phone
<br /> Contractor " 11-11 "vL(: GGf- Address 1
<br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out 01
<br /> nitoring Well ❑
<br /> i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ . OTHER ❑
<br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DI$PdSAL FLD. PROP. LINE :
<br /> �` ' ' PITS/SUMPS
<br /> ` FOUNDATION. AGRICULTURE WELL �STHER WELL
<br /> i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFiCATkONS',
<br /> Dia. of Well Casing'
<br /> ' n Industrial ❑ Open Bottom 0 Manteca Dia, of Well Excavation
<br /> I F.] Domestic/Private 0 Gravel Pack C7 Tracy Type of.,Casing� Specifications
<br /> i 1:3 Other j. 171 Delta f'—Depth of Grout-$oal Type,of Grout
<br /> I'1 Public
<br /> Depth I 1 Eastern Surface Seal Installed
<br /> I I Irrigation —.Approx. by-
<br /> Repair Work Done U Type of Pump H.P, State Work Done '
<br /> Well Destruction ❑ Well Diameter
<br /> Sealing Material & Depth r
<br /> r Depth Filler Material & Depth
<br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION DESTRUCTION I i INo septic system permitted if public sewer is
<br /> `t available within 200 feet,)
<br /> { Installation will serve: Residence Commercial Other.- '
<br /> `Number of living units: •L-- Number of bedrooms
<br /> --- . -71%r—11Vaigr-ta-61e depth
<br /> ''•+,'Chd acter of-soil to if depth of 3'feet;"— T;
<br /> SEPTIC TANK © TypelMfg Y fCapacity � Nod Compartments {� ;
<br /> PKG:;TREATMENT PLT. ❑'T 4 r� Method of Disposal
<br /> l _ ,�. ._Y
<br /> Distance to nearest *Well Foundation Property Line .
<br /> ' f 4
<br /> r ' LEACHING LINE No. $ Length,of lines n — Total lengthl5ize '
<br /> y �a F' ,
<br /> FILTER,BED-�-._..-....--.❑.,....Distance to nearest: Well, Foundation '��-_..._— Property p Y Line
<br /> Size f "NUmbar i
<br /> .SEEPAGE PITS 11 Depth
<br /> _', SUMPS,
<br /> Ll Distance to nearest: Well_ . . „_Foundation Property.,Line
<br /> DISPOSAL PONDS ❑ r b
<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, 4
<br /> r M -• 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 /> r 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 certity,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." r I 1
<br /> The applicant must call for I required inspections...Complete drawing an reverse side. j y
<br /> Signed X -,.-, - -��Tifle: Date: ...,_,/
<br /> :. FOR,DEPARTMENT USE ONLY f
<br /> e v ry
<br /> Dat"0i �� Area
<br /> -{ Application Accepted by
<br /> 7`r Pit or Grout
<br /> In.
<br /> by , ' Date Final inspection by
<br /> Date Qd
<br /> '., Additional Comments:
<br /> Applicant - Return all coples,to: 'San Joaquin County Public Health t ,:
<br /> # ! Services, Environmental Health Permit/Services F
<br /> $g 1601 E. Hazelton Ave., P 0 aox'2009, fit'ocicton, CA "95201
<br /> AMOUNT D'UE1 — ' AMOUNT REMfTTEO + CK , RECEIVED,BY DATI PERMIT'NO.
<br /> ,.,:, �... ....r.-., INFO� :� - -:-.CAS! i' _ _..-
<br /> i
<br /> - i
<br /> Weir 3.26 i
<br /> E vt
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