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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 O BOR 2009, STOCKTON, CA 95201 <br /> EXPIRES 1 YEAR FROM DATE <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 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Joh Address L U' Cit /� �' Got Size/Acreage <br /> Owner's Name �/� � Address !- �3 hrAJ_ _ Phone-) <br /> ,I, <br /> Contractor Address b License No.,Iv1q Phone d' <br /> TYPE OF WELL/PUMP: NE L 0 WELL REPLACEMENT n ESTRUCTION C) Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SE INES ?DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULT LL OTHER WELL PITS/SUMPS <br /> INTENDED USE- TYPE OF WELL PROBLE A CON STRUC PECIFICATIONS <br /> C Industrial ❑ Open Bottom ❑ nteca Dia. of Well Excavation Dia. of Well Casing <br /> P Domestic/Private ❑ Gravel Pack ❑ Tracy -_�. -_Type of Casing Specifications <br /> i'1 Public �01 fl Delta Depth of Grout Seal ype of Grout <br /> I I Irrigation - . Depth I i Eastern Surface Seal Installed by " <br /> Repair Work Done Type of Pump H.P. State Work Done i <br /> Well Destru ❑ Well Diameter Sealing Material & Depth <br /> r Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is r <br /> available within 200 feet.l <br /> Installation will serve: Residence Commercial Other ! F <br /> Number of living units: Number of bedroom <br /> w <br /> Character of soil to a depth of 3 feet: Water table depth , <br /> SEPTIC TANK ❑ Type/Mfg t!r Capacity► .600 _ No. Compartments <br /> PKG. TREATMENT PLT.❑ 4 r Method of D1 sal <br /> Distance to nearest: Well 100 Property Line <br /> Aw <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> r <br /> FILTER HED ❑ Distance to pearest: Well Foundation _y Property Line r <br /> 2_0 -L 5- 6� <br /> SEEPAGE PITS I I Depth l Size Number <br /> r <br /> SUMPS 0 Distance to neaiest: Well Foundation Foundation Property Line <br /> x <br /> w, DISPOSAL PONDS ❑ v ` <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 awner-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: "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 applican -I f al quired inspections. Complete drawing on reverse side <br /> Signed Title: a _ Date: <br /> ` FOR DEPARTMENT-USE ONLY <br /> Application Accepted by �iJ Date ���',r _� Area <br /> Pit or Grout Inspection by Date Final Inspection by .� vt'U Date <br /> Additional Comments: t cU <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Serviceq-�_2rf­�ti �, �' 4�� S)f--e, <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 n e.e. c d� ✓x Iv G� ; s �'lc,� <br /> _r 17,�'11FEE v L Nom` <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. `` <br /> EH 13-241REV.rnsi <br /> EH 7626 <br />