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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 BOX 2009, STOCKTON, CA 95201 <br /> �RRI[_IT EXPIRES 1 YEARFROM DAA <br /> (Complete in Triplicate) <br /> i <br /> Application is hereby made.to San Joaquin County for a permit to construct and/or install the work herein described. This i <br /> in County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> application is made in compliance with San Joaqu <br /> Joaquin County Public Health Services. {7 { <br /> �/ y K X � City of Size/Acreage <br /> f-]ob Address <br /> Address Phone <br /> Owner's <br /> I <br /> ontractaAddress, � � License No.�$� Phone��• <br /> r l-- <br /> TYPE OF WELLIPUMP! NEW WELL ❑ WELL REPLACEMENT LJ DESTRUCTION ❑ Out of Service Well <br /> C7 Cl <br /> PUMP INSTALLATION O SYSTEM REPAIR <br /> OTHER ❑ Monitoring We <br /> DISTANCE TO NEAREST: TANK SEWER LINES DISPOSAL FLD PROP. LINE <br /> PITSlSUMPS �. <br /> FOUND ATI AGRICULTURE WELL OTHE L <br />` „J <br /> INTENDED USE TYPE OF WELL PRO REA CONSTRUCTI ECIFICATkONS Dia. of Well Casing <br /> 11 Industrial ❑ Open Bottom © Manteca is. all Excavation ` <br /> S�cificauons (�1✓� <br /> [I Domestic/Private ❑ Gravel Pack ❑ Tracy Type ing Type of IGrout <br /> F1 Public LI Other to Depth of Grout <br /> I I Irrigation ,— A #. apth I I Eastern Surface Seal Installed State Wor e <br /> Repair Work Done U Type of Pump H.P. S — <br /> R Sealing Material 3 Depth <br /> Well Destruction ❑ Well Diameter Filler Material b Depth <br /> Depth <br /> em <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIRIADDITION l I DESTRUCTION (Nailabltirvsyst 200 feet.) <br /> if public sewer is n <br /> Installation will serve:- Residence_ Commercial_. Other r+ J <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 <br /> PKG. TREATMENT PLT.Cl - - Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. a Length of lines Total length/size <br /> wk <br /> FILTER ICED ❑ Distance to nearest. Well Foundation Property Line <br /> SEEPAGE PITS l I Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS C] <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 taws, 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: "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 applicant c all r Or in pections. Complete drawing on sever ide. l / <br /> XSigned X Title: Date: `� l 1— <br /> OR DEPARTMENT USE ONLY �( �q � <br /> Application Accepted by ate /l'lL' Asa--1C! -- _- Area RM <br /> 1� <br /> III-Ay— <br /> Pit <br /> r-Ay- /tlrS C�eafn�JG 6w,..r� 5 D to <br /> Pit or Grout Inspection by Date Final Inspection by <br /> r_ r <br /> Additional Comments: <br /> Applicant - Return all copies to: San 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 CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO 7 <br /> . EH 13.24{REV.iiKsi �1� �1 �d ��'..�� L*(.a`/ S m /„4,p• izli-I <br /> EH 14-Za 111 <br />