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t i APPLICATION FOR PERMIn <br /> U SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ( i` <br /> ENVIRONMENTAL HEALTH DIVISION SCAN <br /> 1601 E. HAZELTON AVE. , PHONE (209)468--3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> REI YEAR FROM DATE ISSLi <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, 5119 and 1$62 and the Rules and Regulations of San <br /> Joaquin County public Health Services, <br /> f. 4 Job Address City_ Geja✓) Lot Size/Acreage <br /> $ Owner's Name /� �7" rAddress' Phone <br /> Contractor + 1,e f- AddressLicense No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ <br /> WELL.FIE F7 DESTRUCTION 0 Out of Service Well ❑ <br /> M PUMP INSTALLATION El SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <br /> - + DISTANCE TO NEAREST., SEPTIC TANK SEWER LINES DISPOSAL FLp, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> _k <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well.Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications V. <br /> 11Public I:] Other Fi Delta Depth of Grout Seal Type of Grout <br /> I ) Irrivatibn _.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair'Work Done- ❑ Type of Pump H.P. State Work Done _ <br /> Well Destruction 1❑ Well Diameter Sealing Material & Depth <br /> Depth Filler!Material i Depth <br /> a TYPE OF SEPTIC WORK; NEW INSTALLATION 4 1 REPAIR/ADDITION DESTRUCTION i I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> installation will serve: Residence w1w� Commercial— Other LCllb>.avd� <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Lox,k2Q Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKC, TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE PYNo. & Length of lines Total length/size <br /> FILTER BED C) Distance to nearest: Well Foundation — qO r Property Line <br /> SEEPAGE PITS 11 Depth Size Y —Ct — Number <br /> { SUMPS 4;1�Distance to nearest; Weil1 0 6+ Foundation 7,Pproperty Line <br /> DISPOSAL PONDS ❑ ' <br /> 1 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 oi+vner 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 egmpensation laws of California." Contractor's hiring or sub-contracting signature <br /> ccrtifies.the following: "I canify that in the pertormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> f <br /> F1The applicant must call for all requed inspections. Complete drawing ern reverse iside, <br /> Signed X Title: A< T Date: . ! <br /> R DEP RTMENT USE ONLY <br /> Fill Application Accepted by �� t� <br /> Date Area <br /> Pit or Grout Inspection by Date Final Inspection h <br /> Date4� <br /> .� Additional Comments: ' <br /> tt Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Servicee <br /> F! <br /> 1601 E. Hazelton Ave., P 0 Boz 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMIT? CK <br /> INFO EO CASH RECEIVED BYDATE PERMI7'N0. <br /> • EH 13•21 iP <br /> EH 1•$e Ev.r i n s) <br /> 1 <br /> I <br />