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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY `PUBLFC HEALTH SERVICES <br /> ENVIRONMENTAL ,HEALTH DIVISION <br /> 1601' E. HAZELTON AVE' , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> EXP RI'sS 1 YE R FROM DATE ED <br /> (Complete in Triplicate) <br /> I 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 Regul: t` s of San <br /> Joaquin County Public Health Services. <br /> IN l7 `;t 1 Cit Lot Size/Acreage <br /> Job Addres lL! <br /> [ � � Phone <br /> ^^ ;faa O Address <br /> owner!; <br /> License No Z9ZZ.� P <br /> CohonColAddress ►� �" <br /> F TYPE OF WELL/PUMP:, NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION ❑ Out of Service Well ❑ <br /> " OTHER D Monitoring Well C7 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C <br /> DISPOSAL FLD'. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ' —- , <br /> FOUNDATION AGRICULTURE WELL OTHER WELl PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> ' Type of Casing Specifications <br /> t.l <br /> Domestic/Private CI Gravel Pack El Tracy yp g Type of Grout <br /> i Public 1-1 Other i Delta Depth of Grout Seal <br /> I I Irrigation —Approx�. Depth I I Eastern Surface Setil Installed by <br /> r H.P. State Work Done _ <br /> Repair Work Done U Type of Pump <br /> Sealing Material & Depth <br /> Well Destruction ❑ Well Diameter 4 <br /> Depth _ Filler-Mlaterial.&_Depth.- <br /> 4 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR! DDITiO y DESTRUCTION i I <br /> available septic sy t m perfeet. <br /> VII <br /> itMed it public sewer is <br /> F Installation will serve: Residence Commercial Cher -;-�, <br /> Number of living units: _L_ Number of b o ms <br /> Character of soil to a depth of 3 feet: Water table depth, <br /> TANK. Type/Mfg <br /> Capacity � No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal / <br /> t '~,,Distance to nearest: Well Foundation Property Lina <br /> + t7 <br /> Tota length/size <br /> LEACHING LINE No• & Length of lines -' �A <br /> FILTER BED ✓ Cl Distance -Well Foundation <br /> Property Lina <br /> to serest: - <br /> r r t! r <br /> SEEPAGE PITS Depth s Size ? Number <br /> f r r , y' <br /> r SUMPS- s::,.�. f LI�Distance_to nearest: '_Well Foundation <br /> party Line <br /> nP=oc <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this appljcati 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 ''f ` " rformanc/ <br /> Home owner or licensed agent's signature certifies the fol '9 certify that in the pee of the work for-which this permit is issued, I shall not <br /> loNiing: <br /> oy any person in such manner as to become subject to workman s compensation laws of California." Contractor's hiring or subcontracting signature <br /> emply s <br /> empl the following: certify that the performance of the work for,which this permit is issued, I shall employ persons subject to workman's compell <br /> carliF tion laws of California." <br /> The applicant mnt call for req r ed inspections. Complete drawing`on reyers <br /> i <br /> Signed X Title: ate: <br /> FOR DEPARTMENT USE ONLY <br /> ell <br /> A licetian Accepted by 1 Date Area <br /> r_ d <br /> it r Grout Inspection b� ate a4ine! Inspection b Date <br /> I - <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Ravironmental Health Permit/Services <br /> 1601 E. Hill Ave., P 0 Box 2049, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE 9ERM1T NO. <br /> 'm <br /> { <br /> . EH 13-24{REV.I/851INFO '/1o/ 1C�, .c A` - <br /> EH 14.2E <br /> I <br />