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AL <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 0 BOR 2009, STOCKTON, CA 95201 <br /> PERMITT EXPIRES_ 1 YEAR FROM DATE ISSUED <br /> (Complete is 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 compliance 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 City4e4C Lot Size/Acreage <br /> Owner's Name ,'/� '� Address Phon � <br /> l i <br /> Contractor Z Address <br /> —License NIZAS Phone <br /> TYPE QF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of,Service Well 0 <br /> ( PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> Monitoring Well U <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> €f FOUNDATION. AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED ift: TYPE OF WELL' PROBLEM AREA CONSTRUCTION SPECIFICATIONS E <br /> D Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> [I Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications i <br /> I'] Public ITOther n Delta Depth of Grout Seal Type of Grout <br /> I I Irritlation _ Approx. Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth } <br /> Depth` Filler Material & Depth j <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 6+l DESTRUCTION I�I INo septics stem permitted if <br /> :availablwithin 20feet.) <br /> pr'blic sewer is <br /> Installation will serve: Residence i,- -CoOther <br /> Number of living units: Number of <br /> ` gD ' <br /> Character of soil to a depth'of 3�faet: 1 .Water table depth <br /> SEPTIC TANK ❑ II{Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ i a i Method of Disposal 3 <br /> Dista3ce`to nearest: Well Foundation Property Line ^ <br /> LEACHING LINE LNo. & Length of lines Total lengthlsize ' <br /> t <br /> FILTER BED C] Distance to nearest}- Well 020 f` Foundation �` Property Line <br /> 4 1 �� - _ <br /> `` SEEPAGE_. ITS Imo`De/pth.` '�r UrSi:e `R Number •� <br /> SUMPS �•L3f]�stance to iie8rest y Well 1 l_- Foundation ��! Property Line S i <br /> - DISPOSAL PONDS ❑ I �� j <br /> I hereby`cert'ify=that j%have pri3pared.this application arnt�that the work will be done in accordance with San Joaquin county ordinances, state laws, and 1 <br /> rules and regulationsNof the S'an Joaquin County <br /> Home ow4r',,'r 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 parson'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 appiican st I for requir ins cbons. Complete drawing on re,Pr side. <br /> -� - / <br /> Signed X_ r � . ._ Title: C �6�/ � Date: <br /> FOR DEPARTMENT USE ONLY ;! <br /> Application Accepted by ��� Data Area ` ' <br /> /a <br /> Pi or Grout Inspection by - r / ^Final Inspection by _ ata7, <br /> �� <br /> Additional Comments: '. 7dj,2 Ai <br /> Applicant - Return all copies to: San Joaquin County Public Health '!fes 15 i <br /> Services, Environmental Health Permit/Services dd r(J r S <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO, <br /> . fM1324IREV.liNs1� kk . . 11y _Vo �{t7 <br /> EH 21-2E l L <br />