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W <br /> 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 0 BOIL 2009, STOCKTON, CA 95201 ; <br /> I <br /> T E%P RES I YEAR FROM DAT ID � <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 /> Joaquin County Public Health Services. <br /> 77 i(l, City Lot Size/Acreage <br /> ob Address , <br /> Owner {'s Name � f'� � �• <br /> t) Address SI L 7 -�x�n Phone 38 ! <br /> ! <br /> 1 <br /> a icense No. �' Phone it z"' y <br /> Contractor D t 1rrC U� Address <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well El <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 <br /> OTHER ❑ Monitoring Well <br /> DISPOSAL FLU. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES— i <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> L-1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Type of CasingSpecifications (n <br /> (1 Domestic/Private ❑ Gravel Pack C7 Tracy yp Type of Grout <br /> i"1 Public is Other 11 Delta Depth of Grout Seal' _Z <br /> i I Irrigation .Approx. Depth l I Eastern Surface Seal Installed by <br /> H p State Work Done - �! <br /> Repair Work Done ❑ Type of Pump Sealing Material & Depth <br /> i <br /> Well Destruction ❑ Well Diameter <br /> Filler Material & Depth <br /> Depth <br /> PE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION i I DESTRUCTION I I eNailabptic system <br /> m rented it public sewer is <br /> l <br /> Installation will serve: Residence— Commercial_ Other � t � <br /> Number of living units: _!__.__ Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK V Type/Mfg �" � �� Capacity / 0 b No. Compartments <br /> PKG. TREATMENT PLT. Cl Method of Disposal <br /> Distance to nearest:- well Foundation Property Lined t <br /> LEACHING LINE C1 No. & Length of lines �' ►� �'✓� Total length/size <br /> i FILTER BED ❑ Distance to nearest: Well�?�Foundation Property Line /D e <br /> SEEPAGE PITS 11 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 will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, l shall not <br /> Home owner or <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 /> j certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to wo(kman's compensa- <br /> tion laws of California." <br /> The applican ust call for I req iced ctions. Complete drawing on reverse side. p <br /> j � <br /> ed Title: YV C I'- Date: ! - <br /> '& <br /> � � R DEPARTMENT 115E ONLY <br /> Application Accepted by <br /> Date --)- C- Area <br /> Pit or Grout Inspection by Date Final Inspection by D:ste?*A2_, <br /> Additional Comments: <br /> ,G �/�/J' f✓ E� elf "'�t'L- lE' /✓'r¢� <br /> Applicant - Return cops a San Joaquin unty Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE CK RECEIVED BY DATE PERMITN , <br /> j L4 <br /> INF MOUNT DUE A UNT REMITTED CASH <br /> . EH 13.241REV.I/A51 so V Q•0 I fLL-3 <br /> EH 14.28 <br />