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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICTs t '� <br /> V1\9T <br /> ,' ENVIRONMENTAL HEALTH DIVISION <br /> ` 1601 E. HAZELTON AVE- , PHONE (2495201-34 � - <br /> § P O BOX 2009, STOCKTON. <br /> ur�r LRES ALI <br /> 1 _YE FRO D �S ISS T�'D <br /> TH <br /> (Complete in Triplicate) ENViIR�0AN--�%,.r,r-pqT L HEALApplication is hereby made,to San Joaquin County for a permit to construct and/or install the <br /> �E"T,URV&at�lbed. This <br /> with Ban Joaquin County ordinance No. <br /> 549 and 1862 and the Rules and Regulations of San <br /> application is made in compliance <br /> Joaquin County Public Health Services. <br /> Al. City �ck71- Lot Size/Acreage <br /> Job Address I Ta S?RAAT3 <br /> L -4 A01O Phone —. <br /> Is <br /> 's Name G. Address <br /> 3 63 omf-c C1.4e4A/sulrf a 9r 6 <br /> Owner <br /> i C ► �aRpp�' G License No. 2'74-7-$ Phone <br /> Contractor I !-L r NCr Address 6 i <br /> TYPE OF WELLlPUMP: NEW WELL CG WELL REPLACEMENT © DESTRUCTION Out of Service Well ❑ <br /> i <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 13OTHER ❑ Monitoring Well Ci <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES _. DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> 0 Industrial ❑ Open Bottom ❑ Mantaca Dia. of Well Excavation g <br /> ❑ Tracy Type of Casing Specifications <br /> C.] Domastic!Private ❑ Gravel Pack Type of Grout <br /> Il Public II Other 1'1 Delta Depth of Grout Seal <br /> I I trrigation Approx-1 Depth l I Eastern Surface Seal Installed by <br /> Of Pump H.P. State Work Done <br /> Repair Work Dane f3 TYPO Sealing Material ti Depth <br /> Well Destruction ❑ Well Diametlr Filler Material i Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRrADDITION I I DESTRUCTION I I availabo epticle system <br /> m permitted if public sewer is <br /> 200 feet.) <br /> Installation will serve: Residence Commercial` Other <br /> Number of living units: Number of bedrooms �— <br /> Water table depth <br /> Character of soil to a depth of 3 feet: Na. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Capacity <br /> Method of Disposal <br /> PKG. TREATMENT PLT.❑ P �J <br /> Distance io nearest: Well Foundation Property Lina <br /> d <br /> LEACHING LINE. ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance!to nearest: Wall Foundation <br /> Property Line ' <br /> SEEPAGE PITSI I Depth 'I Size Number <br /> SUMPS LI Distance to nearest: - Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 fallowing: '9 certify that in the performance of the work for which this permit is issued, I 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 shall employ persons subject to workman's compensa- <br /> tion laws of California." 1 <br /> The applicant must_ II for all require 'nspec Complete drawing on reverse side. <br /> _ Date: <br /> $ q <br /> FOR DEPARTMENT USE ONLY <br /> Data � Area <br /> Application Accepted by <br /> Pit or Grout Inspection by <br /> Date Final Inspection by Date <br /> Additional Comments: <br /> �t San <br /> Applicant - Return all copies to: 3etvi �aP.aCvi oti ntal Healthy Public tPermit/Services <br /> 1601 E. Hazelton Ave., P O Box 2009, Stockton, CA 95201 'r <br /> HAMOUNT DUE AMOUNT REMITTED ECEIVED BY DATE PERMIT'NO. <br /> ffFEECASH 4 ll <br /> If��EH 17.21(REV.t/r3) O � - <br /> EH—2a <br />