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APPLICATION FOR PERMIT �' <br /> : " � <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION JUN 13 <br /> 1601 E. HAZELTON AVE. , PHONE (209)46��iNM�� AL gyp, <br /> P 0 BOX 2009, STOCKTON, CA 9520 <br /> PERMIT/SERVICES <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in 'Triplicate) j <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 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Healthh'8 rvic/eo. <br /> Job Address tom/' u���- � City L Lot Size/Acreage <br /> RJ <br /> Owner's Name ��� � <br /> & E1�!C Address l Phone f <br /> Contractor Address 3(0 U License No, ?fes Phone r ; <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well <br /> PUMP INSTALLATION © SYSTEM REPAIR OTHER ❑ monitoring Well <br /> C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .T <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 'f <br /> Domestic/Private ❑ Gravel Pack C7 Tracy Type of Casing Specifications <br /> /('1 Public (a Other • _ .» C-1 Deka „� Depth-of Grout-Seal . Type of Grout 1 <br /> I I Irrigation Approx. Depth I I Eastern Surface Seal installed by <br /> Repair Work Done E] Type of Pump %9A H.P. ' State Work Done <br /> Well Destruction O Well Diameter r Sealing,Material i& Depth <br /> Depth � Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION ( I (No septic system permitted if public sewer is <br /> a%ailabfe within 2W,1eet.) I <br /> Installation will serve: Residence_ Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character of Boit to a depth of 3 feet: Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE D No. & Length of lines Total length/size t <br /> FILTER BED Ll Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number \ <br /> SUMPS LI Distance to nearest: Well 1 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, an66� <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 per m such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the f to rng: "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 ifornia. <br /> r f <br /> The app' must tail for alts qu rad inspe, i s. C mplete drawing on rover" side. x <br /> Signed X I Title: MA-AQ!$X_� Date: <br /> { Q s <br /> OR DEPARTMEN SE ONLY <br /> Application A_ccepted:by _ Date Area <br /> Pit or Grout Inspection-by Date Final Inspection by Date <br /> I <br /> Additional Comments: ! <br /> Applicant - Returnallcopies to. San Joaquin County Public Health i <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE ;PERMIT'NO. <br /> + A <br /> aEH 13-24(REV.lin 5) -r,�� 7� �� .l1 i <br /> EH 14-26 `� <br />