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li 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 BO% 2009, STOCKTON, "CA 95201 <br /> t <br /> pIMIT <br /> T%P RTS 3 YEAR FR M DAT ED <br /> 1 (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 1862 and the Rules and Regulations of San <br />!f Joaquin County Public Health Services. <br /> � ,t� <br /> rJ 7 ^/, t�v j�S o� yv City S Lot Size/Acreage 6 7 <br /> Job Address �} <br /> Owner's Name ` t p Address J ,3 7 L-!6 Phone y <br /> Contractor 6'+•Yd 1PJ' .0 Address License No. Phone <br /> i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Dut of Service Well C1 <br /> Monitoring Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> {1 Industrial ❑ Open Bottom C1 Manteca Dia. of Well Excavation Dia. of Welt Casing <br /> [I Domestic/Private ❑ Gravel Pack L1 Tracy Type of Casing Specifications <br /> I'1 Public Cl Other n Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation —Approx. Depth t I Eastern Surface Seal Installed by <br /> Repair Work Done L1 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter <br /> Sealing Material & Depth <br /> Depth Piller Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l 1 DESTRUCTION l 1 (No septic system permitted it public sewer is <br /> available within 200 feet.l <br /> Installation will serve: Residence— Commercial Z Other <br /> Number of living units: Number of be rooms r <br /> !!! Character of soil to a depth of 3 feet: a744 Water table depth <br /> SEPTIC TANK. 9r Type/Mfg / �- — Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well 4']Q& - Foundation S Property Line 4/0S� <br /> LEACHING LINE 6 No. & Length of lines Q O'* Total length/size 120 <br /> FILTER BED ❑ Distance to nearest: Well S�'da_ Foundatidn —a? Property Line _ 1/0 <br /> SEEPAGE PITS 14K Depth 9 A —Size Number <br /> SUMPS LI Distance to neare� Well &06 Foundation Property Line y� y <br /> l <br /> DISPOSAL PONDS D <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, an <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: "I certify that in the perlormance 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 MoAwor all required inspections. Complete drawing on reverse side. <br /> Signed X Title: 14t A s_r' - _ Date: <br /> E <br /> USE ONLY <br /> kApplication Accepted by Date _ - 1.y_._ Area ` <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: Joaquin County Public lth <br /> # Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009. Stockton, CA 95201 <br /> o FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE ARMIT"N0. <br /> tI INFO <br /> F a EH 13-24IREV.1/A51 - <br /> EH 14-W <br />