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rT <br /> APPLICATION VOR PERMIT r 4 ( [� <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ' <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Ak <br /> 1601 E. HAZELTON AVE. , PHONE (209)463420 <br /> 8 <br /> r <br /> P O BOX 2009, .STOCSTON, CA 95201 <br /> ?EPJITT 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 instal.. the vork 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 1 <br /> Joaquin County Public Health Services. <br /> City r Lot Size/Acreage ' <br /> Job Address l�ivvf••• <br /> Owner's Nam <br /> Addresse3 Z Phone <br /> 4 <br /> Contractor Address - License N� St=Phone <br /> WELL REPLACEMENT 0 DESTRUCTION 0 Out of Service Well ❑ <br /> P: NEW WELL © _ <br /> TYPE OF WELL/PUMP: _ ,. .,, -. � <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEVNER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF'WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> E7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I I'1 Public C7 Other 1­1 Delta Depth of Grout Seal Type of Grout <br /> Irri{)ation a —,Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump% H.P. State Work Dona <br /> Well Destruction ❑ Weil Diameter Sealing Material 3 Depth <br /> I Depth ! Filler:Material&,Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION ! I DESTRUCTION I I INo septic system permitted it pubfic,sem6 r is <br /> available within 200 feet,) <br /> Installation will serve: Residence_ Commercial_ Other '{ <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. _p Type/Mfg Capacity No. Compartments <br /> I ' PKG. TREATMENT PLT.❑' { <br /> • <br /> Method ni Disposal <br /> .Distance to nearest: Well Foundation Property Line <br /> I LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS _ .�[ I Depth Size Number a <br /> L ,_ SUMPS LI Distance to nearest: Well -- Foundation Property Line r <br /> DISPOSAL PONDS - ❑ t 4 <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, I shall not <br /> t amploy any per'son in such manner as to'become subject to workman's compensation laws of California." Contractor's hiring or subcontracting 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 ompe a <br /> tion laws of California." <br /> d Thea nt mu call for all req red ' pectin . Complete drawing'0 verse side, <br /> l w <br /> Signed X Title: Date: <br /> �_ FORIFARTII�ENT USE ONLY <br /> i Application Accepted,by,. Date Area / <br /> { . Pit or Grout inspection by Date Final Inspection by Date( � � <br /> 7 <br /> Additional Comments:. `� / <br /> f Applicant - Return all copies to: San Joaquin tounty Public Health t4) � ! ✓ <br /> Services, Environmental Health Permit/Services <br /> f 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE }AMOUNT OtJls AMOUNT REMITTED CK RECEIVED BY DATE PERMIT•NO. V, <br /> INFO CASH tt('� <br /> , EH13.241REV.iirr5i �.D"� IF. :�� t\J <br /> EK 9426 <br />