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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION' t <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PEMIT Lyp ICES 1 YE R RO DATE I&UM <br /> (Complete in Triplicate) <br /> madeto Sea Joaquin Ceunty nan <br /> for a permit to construct and/or install the work herein described. This <br /> Application to hereby m - <br /> application is mere in ade. in County ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> compliance with San Joaqu <br /> Joaquin County Public Health Services. <br /> 7 7 7 5' � Ll.+.Y� ��-�y City_.�----- Lot Size/Acreage <br /> Job Address <br /> ALC--Q- <br /> � �­ <br /> 1) <br /> r� Phone <br /> Owner's Name Address ILtS 11�= Q <br /> ` License No.� Phone ^-� <br /> Contractor Address � �` <br /> WELL ❑ WELL REPLACEMENT Q DESTRUCT-IQN C a+t of Service Well Cl <br /> NEW <br /> TYPE OF WELL/PUMP OTHER G Monitoring Well <br /> PUMP INSTALLATION C SYSTEM REPAIR D Y " , <br /> SEWER LINES__ DISPOSAL FLO. PROP. LINE <br /> l DISTANCE 70 NEAREST: SEPTIC TANK PITSISUPS <br /> y FOUNDATION AGRICULTURE WELL OTHER WELL M <br /> INTENDED USE ��, TYPE OF WELL'' LEM AREA CONSTRUCTION SPECIFICATIONS Dia of Wait Casing �J <br /> 1 Industrial.- CI Open Bottom D Manteca Dia- of Well Excavation Specifications <br /> fFJ Domestic/Private D Gravel Pack L] Tracy Type of Casing_.. <br /> (� Delta Surf <br /> Depth of Grout Seal- Type of Grout <br /> ('! Public " :1 Other u. <br /> ✓ w_ -_fi <br /> k I I Irr gation 1__Approx. Depth C]-Eastern � ace Seal Installed by t <br /> IHP State Work-Done <br /> U , <br /> Repair Work Done Type of Pump t <br /> Sealing Material & Depth <br /> Weft Destruction O Well Diameter <br /> .Piller Material & Depth <br /> Depth _ <br /> TRUCTION I 1 (No septic system permitted if public sewer is <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t 1. REPAIR/ADDITION available within 200 feet.) <br /> Installation will serve:- Residence Commercialther ` <br /> Number of living units:___L Number of bedrooms <br /> ---+ <br /> or table depth <br /> Wat ' <br /> I Character of soii-to-e_depth of 3 feet: <br /> SEPTIC TANK D`Type/Mfg Capacity No. Compartments p <br /> Method of Disposal <br /> PKG. TREATMENT PLT-0 t <br /> ~ distance tonearest: Well Foundation Property Lina t. <br /> t� t <br /> j P-170. �7TI length/size <br /> LEACHING LINE & Length of.lineso <br /> S E <br /> I!` V FILTER BED Eltonearest:. Wel( Foundation Distance ' L�!_ Fndation -- Property Line <br /> I <br /> �. . <br /> SEEPAGE PITS L1 Eiapth n� Size Number <br /> 1 SUMPS LI Distance to nearest: Welt Foundation� Property Line <br /> DISPOSAL PONDS Q <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 /> Home owner or licensed agent's signaftre 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 /> tio laws of California" <br /> The apple m st call f all uire ins omplete drawing ons verse side. <br /> — <br /> Title:- Date: 7 <br /> Sig <br /> aS.0EPARTIMENT U5E ONLY` <br /> ' Date ' Area <br /> Application Accepted by _ ^•- <br /> Pit or Grout Inspection by Date' Final Inspection by ate <br /> I <br /> r <br /> Additional Comments: <br /> Applicant - Return cop o: lan i oaquin CotmtFu <br /> ,f$ervicea,Environmental Health Fermat/Services <br /> ` 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> t FEE CK RECEIVED BY "DATE PERMIT"NO. <br /> INFO AMOUNT OtJE AMOUNT REMITTED CASH <br /> ` <br /> -7. 'A r <br /> I EM 13.24 I REV.ii 951 �� � � <br /> EM 14.26 <br />