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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)465-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201. <br /> PERMIT EXPIRES 1 YEAR FRAM,DATE ISSUTBD CA <br /> h� � <br /> r.t- _ � , P;t�. <br /> (Complete in Triplicate) irL6�. <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 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Jab Address JA <br /> City of Size/Acreage <br /> Owner's Name �� Address �� Phone � Z <br /> Con r Address License No. Phone <br /> TYPE OF WELL/ NEW WELL ❑ WELL REPLACEMENT ❑ OESTRUCTION ❑ Out of Service Well ❑ <br /> PU ALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ M oring Well <br /> DISTANCE TO NEAREST: SEPTIC TAN I SEWER LINES DISPOSAL FLD. ROP. LINE <br /> F <br /> FOUNDATION I ICULTURE WELL 0 L PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA N SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca ia. o xcavation Dia, of Well Casing <br /> [I Domestic/Private ❑ Gravel Pack ;I cy Type of Casing_ Specifications <br /> Il Public EI Other F1 Delta Depth of Grout Seal Type of Grout O <br /> t I Irrigation prox. Depth 1 I Eastern Surface Seal Installed by <br /> Repair Work Done Type of Pump H,P. State Work Done <br /> Well Destru 0 Well Diameter Sealing Material & Depth <br /> Depth �` Piller Material & Depth <br /> TYPE OF SEPTIC WORK: NEW,INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION (No septic system permitted it public sewer is <br /> available within 200 feet.] <br /> Installation will serve: Residence Commercial— Other ►►►iii <br /> Number of living units: p Number11 of bedrooms p <br /> Character of soil to a depth of 3 feat: — Dde th <br /> SEPTIC TANK 0 Type/Mfg Ca�j�dxX�3TCE(f V�11 partrttents <br /> PKG: TREATMENT PLT.Cl �rm� mal d Method 1 Disposal <br /> Distance to nearest: Well _ work Mii1�tiM01PIed <br /> LEACHING LINEL"1 No. & Length of lines Total length/size <br /> FILTER BED Cl Distance to nearest: Well Foundation Property Line <br /> :I. <br /> .r <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 /> Home owner 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 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 /> tion laws of California." - - ` <br /> The applicant must call for a required inspections..Complete.drawing on.reverse side, r <br /> lee Signed X , art- G1- __-r Title: Date: Z <br /> OR DEPARTMENT USE ONLY'_ [ <br /> Application Accepted by Date Jr''�i�f Area _ <br /> iS <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> it <br /> Additional Comments: <br /> ,I <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 /> lFEEO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> EH 13-24 t11Ev.tirssl S)q <br /> EH 11.2E <br />