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- APPLICATION FOR PERMIT <br /> SAN JOAQUIN CgUNmYtPUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 9)468 <br /> P O E. BOX 2009ZELTON �,VSTOCKTUN, CAE. , PHONE 95201 <br /> •'T E IRBS 1 YEAR Fft4M DATE ISSUffif <br /> (Complete in Triplicate) <br /> to San Joaquin County for a permit to construct and/or install the work herein described. <br /> Application is hereby made This <br /> application is made in cowliance with San Joaquin county Ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> /7 ry� S Cit> 0 Lot Size/Acreage -- <br /> Job Address 1 / <br /> S 1 • � Phone— 9 i- is <br /> Address t- <br /> Owner's Name <br /> ! <br /> n , �9 l�D0d �License No. D31v3 Phone G Grp�s6 7 <br /> Contractor! � � dress '—T— DESTRUCTION LOut of Service Well ❑ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT '.JMonitor:ing <br /> PUMP INSTALLATION ❑ Well <br /> SYSTEM REPAIR C', OTHER C <br /> PROP. LINE-If-AW <br /> SEINER LINES -� DISPOSAL FLO.N�--- <br /> DISTANCE TO NEAREST: SEPTIC TANK►-�� PITS/SUMPS <br /> FOUNDATION h AGRICULTURE WELL-- OTHER WELL <br /> PROBLEM AREA CONSTRUCTION SPECIFICAT NS <br /> TYPE OF WELL <br /> INTENDED USE �— - Dia. of Well Casing <br /> Ci Industrial ❑ Open Bottom G Manteca Dia. of Well Excavation� Specifications <br /> �1 Gravel Pack n Tracy Type of Casing. 77— At, <br /> ` Domestic/Private Type of Grou <br /> is Other I1 Delta Depth of Grout Seal --- <br /> FI Public b <br /> IrriUation Z20 Approx. Depth I I Eastern Surface Seal Installed by <br /> H.P. State Work Done _ <br /> Repair Work Done L3 Type of Pump Seslirtg Material 6 Depth <br /> Well Destruction ❑ Well Diameter Filler Material 6 Depth <br /> Depthrmittnd it public sower is <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I availablerwithin 200 feet.l system p <br /> 1 <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 lest: Capacity No. Compartments <br /> SEPTIC TANK. O Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. C': Property Line <br /> Distance to nearest: Well Foundation <br /> r <br /> Total Iength/size <br /> LEACHING LINE Cl No. 8 Length of lines Property Line <br /> FILTER BED (.1 Distance to nearest: Well Foundation _ <br /> t <br /> I I Depth Size . Number <br /> SEEPAGE PITS — property Line <br /> SUMPS I.; Distance to nearest: Well _ Foundation_.. <br /> /DISPOSAL PONDS U <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 /> ollowing: "1 certify that in tftib performance of the work for which this permit is issu <br /> Home owner or licensed agent's signature certifies the fed, 1 shalt 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 /> ti s of California." <br /> T e appt nt mu call t r h required inspections. Complete drawing verse side. /5— O� <br /> Title: <br /> Date: J <br /> Sig <br /> FOR EPARTMENT USE ONL /�' <br /> Date� / l a Area 12 1 <br /> A - Ion Accepted by <br /> Date Z3 D Final Inspection by Date ��l <br /> 1. <br /> Pit or Grout Inspection b� �� <br /> y � �1/� C1 ��- � <br /> ? Additional Comments: <br /> Applicant - Return all copies to: Joaquin County Public Health <br /> i Services, Envlrottmenta.l Health Permit/Services <br /> 1601 k. Hazelton Ave., P Box 2009, Stockton, CA 95201 <br /> K RECEIVED By DATE PERMIT NO. <br /> FEE AMOUNT DUE MOUNT REMITTED t H <br /> INFO Q <br /> to 74-90 <br /> . EH 13-24IREV. <br /> EH 14"26 <br />