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i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 R. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> pOWIT EXP RES 1 YEAR FROM DATE ISSED <br /> ff (Complete in Triplicate) <br /> �:1 <br /> This <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. <br /> application is trade in-compliance frith San Joaquin County ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> C of Size/Acreage <br /> Jab Address <br /> A 9� <br /> Address Phone/� I <br /> Owners r ;; i r - ! <br /> - cense N,40_1Phone <br /> C ntractor Ad ss <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLAC ENT M DESTRUCTION ❑ Out of service Well 0 <br /> { SYSTEM REPAIR OTHER ❑ Monitors Well <br /> PUMP INSTALLATION ❑ } 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWEIR LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL- <br /> INTENDED <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> _j Dia. of Well Casin <br /> Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation g <br /> ❑ <br /> 1.1 Domestic;Private ❑ Gravel Pack ❑ TracyfLf Type of Cas Type <br /> Specifications <br /> C1 1 Other 11 Delta I Depth of Groii t Seat Type of Grout j <br /> Cl Public 1 ' <br /> I Irrioa0en _.Approx. Depth I I Eastern Surface Seal Installe by ! <br /> Repair Work Done U Type of Pump H.P I State Work Don <br /> SeAling Material <br /> Well Destruction ❑ Well Diameter �'I <br /> Depth Filler Material 8 I>ep�h� <br /> TYPE Of SEPTIC WORK; NEW INSTALLATION I 1 REPAIR!'ADDITION i I DESTRU TION I I (No teptic system permitted if public sewer is <br /> availbble within 200 feet.1 <br /> Installation will serve: Residence I Commercial— Other r-"-" ar t - _T__ <br /> Number of living units; Number of bedrooms 1 4:57. <br /> Character of soil to a depth of 3 feet: j I I " Wa er table depth <br /> SEPTIC TANK. ❑ Type/Mfg !! - Eapatity� `� �tN ompartments <br /> PKG. TREATMENT PLT. ❑ 1 Method of Disposal <br /> Distance to nearest: well I Foundation _�_ Property Line <br /> LEACHING LINE ❑ No. & Length of lines �" �%�'^ Total length/size <br /> FILTER BED ❑ Distance tp nearest: Well_ I✓ Foundairo Property Line <br /> II i <br /> SEEPAGE PITS/, 11 Depth Size Number <br /> SUMPS J l! Distance;to nearest: Well i Foundation Property Line <br /> + s <br /> DISPOSAL PONIIS ❑ ! ! <br /> I hereby cartify 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 rJbagdin County <br /> Home own�r_oWicensed agents signature cenifies the followings-ce 'fy thar in_the_pe.dormance-of.the-work-for_which_thi"ermit-is-issued,..,-shall.not <br /> employany personin 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 ywhich this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion taws of California." I - 1 <br /> The applicant call f it i d inspections. Complete drt ing on re se side. Ia <br /> Signeditl Date; ` D <br /> 1 <br /> F DEPARTMENT USE ONLY ! �{ <br /> Application Accepted by _ t _. Data Area <br /> Pit or Grout Inspection by �^ Date _ — Final Inspection by ', Date ({ <br /> Additional Comments: <br /> Applicant - Return all copies tot San Joaquin County, Public Health <br /> Services, Fltvironmental Health Permit/Services 1v� <br /> 1601 E. Hazelton A�e.,]P 0 Box 2009, Stockton, CA 95201 <br /> FEEAlNOUNT Dt1E f AMOUNT REMITTE I ASH RECEIVED BY DATE PERMIT N0. <br /> INFO � 76 <br /> ♦ EH 13.24 Mev.I M <br /> EH A•26 <br />