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it <br /> j� <br /> APPLICATION FOR PERIiIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> I� ? ENVIRONMENTAL HEALTH DIVISION <br /> jj <br /> 1601,,:E.. HAZELTON AVE. , PHONE (209)468-3420 <br /> 0 BOX 2009, STOCKTON, CA 95201 <br /> jI <br /> PERMIT EXPIRES 1. YEAR FROM DATE ISSUED <br /> i (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 ceMliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. / <br /> Job Address f�,L( �y /ol_ / City �a`�/ d7a Lot Size/Acreage <br /> �—_Owner's.Name— o- ..Address ^ %�` Phone, <br /> . �� <br /> Contractor,-�'�s /5;Z <br /> 4'4Z�,- `Address TT License No. Phone _. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ ? WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP,. LINE <br /> FOUNDATION ! AGRICULTURE WELL OTi� WEbt PITSI'S'UMPS <br /> INTENDED USE TYPE OF WELL I PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> P Domestic/Private ❑ Gr'avel Pack i 0 Tracy Type of Casing Specifications ' <br /> Il Public r El Other n Delta Depth of Grout Seal, Type Jot,Grout <br /> 1. i ! <br /> I I Irrigation f§ _Approx. DeptI4 t I Eastern r Surface Seal;installed,by <br /> Repair Work 041n Type iof Pump H.Pi , lState�/Vork Done <br /> Well Destruction ❑ Well Diameter t Sealing Material & Depth <br /> j Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if publicsewe� <br /> ' available within 200 feet.) .( J•' <br /> Installation will serve: Residence 2!t_'Comercial—Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: ' V Water table depth <br /> t <br /> P ' <br /> SEPTIC TANK. ❑ Type/Mfg ,, ,,- Capacity No. compartments ) <br /> PKG. TREATMENT_ PLT.❑ �� - J .,. Method of Disposal �_...,i 3 -`I fi <br /> f� distance to nearest: WeII 19� Foundation Property Line <br /> LEACHING LINE 'No. & Length of Mines Total length/size �7— <br /> FILTER BED 11 Distance to nearest: .VIJetL/�� Foundation", Property Line �&ITJ <br /> SEEPAGE PITS [ I Depth Size r _ Number t f r`i <br /> SUMPS Ll Distance to.nearest: Well Foundationt Property,Line ' <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinance"s,''state laws, and <br /> rules and regulations of the'San''Joaquin County [ r ` <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 persokirI such manner as to become subject to workmanis compensation laws-of,Califorr�is: Contractor's hiring-;or rub-contracting signature <br /> certifies the f6$6wing: "I certify that in the pefformance of't_ha work fol which this permit is issued,f`shall employ persons subjecrto workman's compensa- <br /> ,tionlawe,of California." _.X1 <br /> The applicant must call for all requ d inspections. Complete drawing an reverse side. <br /> Signed `-^ Title Date: < < I <br />• '� _ _ FDEpA� <br /> _~ENT U�—ONLY__.._ _•..........--._ _. -s.w h�- i <br /> ct" <br /> Application Accepted by Date Arex; <br /> I <br /> Pit or Grout Inspection by Date Final Inspection by Date � <br /> Additional Comments: ;I <br /> �I <br /> Applicant — Return all copies to: San Joaquin County Public Health <br /> Services, .Environmental Health Permit/Services l 1601 E. Hazelton Ave., P O Box 2009,°.Stockton, CA 95201 <br /> INFO RUNT DUE AMOUNT REMITTED CASH RE1.CEIVED BY DATE PERMIT NO, <br /> * EEH 13-24 H 14•�'AEV.1/ 5) <br /> `( 13d .% <br />