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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> } : 1601 E. HAZE BOX TON2ooAVS . 1 PHON <br /> TOCgTONE CA <br /> AOg520g--3420 <br /> RES J YEAR FROM DAT <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 1862 and the Rules and Regulations of San <br /> I r <br /> Joaquin County Public Health Services. <br /> C $ `rCity Lot Size/Acreage <br /> Job Address n f <br /> f02- '�t 'r G M�. � Phone <br /> Owner's Name -Address 21- Q <br /> Contractor Address <br /> License No. _Phone <br /> DESTRUCTION Out of S <br /> TYPE Of WELLIPUMP: NEW WELL LJWELLMonitorWELL REPLACEMENT `Q Monitoring. <br /> ❑ <br /> g.well ❑ <br /> F PUMP INSTALLATION 0 SYSTEM REPAIR ❑ <br /> D <br /> f �. <br /> SEWER LINES <br /> �-- DISPOSAL FLO, I-' PROP• LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA 'CONSTRUCTION SPECIFICATIONS <br /> i Dia. of Well Excavation <br /> nc�s Dia. of Well Casing <br /> C7 Industrial ❑ Open Bottom ❑.Manteca <br /> Type of Casing Specifications <br /> f7 Domestic/Private ❑ Gravel Pack ❑ Tracy(=� Other Type of Grout <br /> I"i Public her Cl Delta Depth of Grout Seal <br /> i I PtsbliIrrigation --Approx. Depth I I Eastern Surface Seal Installed by <br /> H P State Work Done <br /> Repair Work Done 0 Type of Pump Sealing Material & Depth <br /> Wel! Destruction ❑ Well Diameter Filler Material 8 Depth <br /> Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION f I •REPAIR/ADDITION i I- DE=STRUCTION I I'INo sblei tic system Perm <br /> availaithin teethed it public sewer is <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 feel: <br /> SEPTIC TANK ❑ Type/Mfg Capacity_ Na. Compartments <br /> PKG.\TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> I LEACHING LINE CINo. & Length of lines Total lengthlsixe <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> a <br /> SEEPAGE PITS 1 l Depth :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,41t be dd'ne in accordance with San Joaquin county ordinances, state laws, and <br /> 1 rules and regulations of the San Joaquin County r <br /> Home owner or licensed agent's signature certifies the following:­1 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." Contractors hiring or subcontracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shah employ persons subject to workman's compansa- <br /> tion Jaws of California." _. <br /> The applicant must call for*IireaMpred 'nspections ompl`to drawing on reverse side. <br /> �( S <br /> Title: <br /> igned Date: C� <br /> DEPARTMENT USE ONLY <br /> Application Accepted by `tom Date Area ` <br /> Pit or Grout Inspection by Date <br /> Final Inspection by % vi Date <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 PERM17 NO. <br /> INFO <br /> . EH 13-24(REV.$1A5) ��� �✓ CD <br /> w EH 14.26 <br />