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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONM + - <br /> TAL HEALTH DIVISION <br /> 1601 E HAZEL ON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOC%TON, CA 95201 <br /> gEMIT EXP RES 1 YEAR FROM DA E RD <br /> (COmplete in 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 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Servicfe^s.,, <br /> t Job Address C1/ L� GZ:I- "City�e��lt'r�{C ALU Size/Acreage <br /> Owner's Name d e, Address /U< G Phone <br /> 4 � r . <br /> -Contractor .F-vL� - ---Address• -- /12 -L°1 - -4tense-N© <br /> Phone <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT L7 DESTRUCTION ❑ Out of Service Well C7 <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL -• PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f <br /> C7 Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation s Dia. of Well Casing <br /> I-) Domestic/Private Cl Gravel Pack 11 Tracy Type of Casing Specifications_ _ <br /> I'I Public 1-1 Other 11-Delta -Depth of Grout Seal Type of Grout <br /> i I Irrigation �,Approx. Depth I I Eastern Surface Seal installed by <br /> Repair Work Done L] Type of Pump H.P. State Work Dana <br /> Well Destruction _ D Well Diameter Sealing Naterial & Depth <br /> ~Depth Filler Material & Depth i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION <br /> DESTRUCTION I I (No septic system permitted it public sewer is <br /> Installation will serve: Residence available within 200 feet.) <br /> Commercial_ Other <br /> Number of living units: _; Number of bedrooms -. <br /> Character of soil to a depth of 3 feet: Water table depth , <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments e <br /> PKG. TREATMENT PLT. Cl F Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ' No. & Length of linesl="� `' <br /> ' � Total length/size <br /> FILTER BED 0 Distance to nearest: Well—C,3 10—Toundatjon �T <br /> y�F Prrooperty Line--� <br /> . SEEPAGE PITS I'I Depth Size's 731 � __Number <br /> L <br /> SUMPS ly Distance to nearest.. Well ,�r�Foundation Y12"I Proms <br /> party Line <br /> DISPOSAL PONDS p '•� <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 following: "I 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: "1 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 applicant must call for all equired ' spections. Complete drawing on reverse side. <br /> Signed <br /> Title: Date: <br /> �F7RDEP7ATME7TUSIE ONLY <br /> Application Accepted by7 (T <br /> Date rea <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: Ban Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave.. P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE :AMOUNT REMITTED CKINFOASH RECEIVED BY DATE PERMIT"NO. <br /> EH 14.24 1flEV,1 N 5r �� �E!r i{•2tS l <br />