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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 p•0 BOXLTON AVE. , PHONE 2009, STOCKTON, CA 95201 <br /> EXPIRES 1 YEAAR FR M A T <br /> (Complete in Triplicate) <br /> tall <br /> work <br /> in <br /> application is herebinmade.11Sananee xithu9anin CJoa4uinounty oCounty Ordinancer a permit to nNoru51+9ct &and 1862sand the eRules andeRegulations dof San <br /> s <br /> mad <br /> Joaquin County Public Health Services. <br /> City t Size/Acreage <br /> Job Address <br /> N } Address:q <br /> Phone X51 <br /> Owner's Name' �f <br /> _ ? <br /> r S - <br /> ---License-No.0 i-s� -Phone!lContractor- - ddress -/ <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well Cl <br /> 'rTYPE OF WELL/PUMP: - OTHER ❑ Monitoring Well C.I. <br /> ----------- <br /> PUMP INSTALLATION ❑ SYSTEM REP 1R <br /> i '" SEWER LIN DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTICaTANK ��— AGR UL <br /> WE OTHER WELL PITWSUMPS .� <br /> FOUNDATION.�_�___— <br /> �f <br /> INTENDED USE TYPE OF WELL PROBL_ LEM AREA CO RUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Open Bottom ❑ Manteca Di of Well Excavation <br /> Ll Industrial Specifications <br /> e of Casing <br /> [I Domestic/Private �❑ Gravel Pack C3 Tracy D th of Grout Seal Type of Grout <br /> I'1 Public I-1 Other n Delta <br /> I i Irrigation -Approx. Depth I I Eastern S rface Seal Installed by <br /> ' of Pump H.P. <br /> State Work Dona <br /> Repair Work Done U Typo Sealing Material & Depth <br /> ell Destruction 0 tWeil Diameter �— Filler Mate Depth <br /> ;path <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION [ I REPAIR/ADDiTIO I ESTRUCTION l I (No septic system permitted it public sewer is <br /> l r �_.. � �ava- ble thin 200 fiat. <br /> 21000 t <br /> f ? <br /> installation will serve:: Residence Commercial Other c <br /> Number of living.units: Number of bedrooms r <br /> # Wat able de�t� / <br /> Chiracter of soil to a,depth of 3 feet: <br /> Capacit� No. Compartments <br /> SEPTIC TANKS © Type/Mfg Method of Dispopral <br /> PKG. TREATMENT PLT. I❑ _M - t.. <br /> 4 Distance to nearest:, Well Foundation Property Line <br /> 1 a Wit. J .4 s f <br /> r L-£ACHING LINE ❑ No. & Length of lines 7 at length/size <br /> FILTER BED J + Cl 1'Distance to nearest: Well Fou dation Property Line (� _ <br /> SiEEPAGE PITS 11 f Depth Size =Nu bar 2 <br /> I � C1 Distance to nearest: Well oundation <br /> _ Property Line <br /> SUMPS <br /> pkSPOSAL PONDS ❑ � � {• i <br /> I hereby certify that l have prepared this application and that the work will be'done in accordance with San Joaquiri county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the fallowing: "I certify that in the performance of the work for which this permit is issued, k 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 shelf employ persons subject to workman's comp ensaI <br /> tion laws of California." <br /> The applican uSt call fo required ins ctions. Complete drawing on reverse side. r� <br /> evllll� A4 Date: <br /> Signed Title: <br /> << <br /> F DEPARTMENT USE ONLY f <br /> I Area <br /> ' Application Accepted by ate <br /> Date <br /> Final Inspection by Dat <br /> Pit or Grout Inspection by <br /> Z j <br /> T ' <br /> Additional Comments: <br /> Applicant - Return a.11 copies to: San Joaquin County Public Health r <br /> Services, Environmental health Permit/Services <br /> l 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMt7'NO. <br /> INFO <br /> r EN 13-24IREV,I/H51 Af, `-' + • <br /> i EH 24.25 <br />