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APPLICATION FOR PERMIT i <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> s .gj-,ntzuruJT EXPIRES 1 YEAR FROM DATE ISSUO. <br /> ' (Complete in Triplicate) <br /> Application is hereby made to S"toaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in ccmpliance'with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> 1 <br /> Joaquin County Public Health 8 r ces. <br /> �/ r + Lot Site/Acreage <br /> Job Address - - City i <br /> I <br /> �� 33y Ya <br /> r L2 Address Phone <br /> Owner's Name <br /> %Contractor <br /> i `��t r2/L. Address License No.4� Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ _ WELL REPLACEMENT ❑ DESTRUCTION Vout <br /> of Service Well 0 <br /> Monitoring Well 7 <br /> BOTHER ❑. <br /> PUMP„INSTALLATION ❑ r SYSTEM REPAIR ❑ 1.: __ <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES DISPOSAL FLD. PROP.`LINE <br /> FOUNDATION] '« AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> TENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> t, ndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> f:7 <br /> Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing <br /> Specifications <br /> i'1 Public I.7 Other � :. , <br /> �'0 Delta Depth,of Grout Seal Type of Grout ° <br /> I'I Irrigation 4 4 ,. Approx. Depth € I Eastern t Surface Seal Installed by i< <br /> H P, State Work Done.— <br /> i Repair Work Donk. U, ._Type_of_Rump_ rsv > + <br /> Sealing Material & Depth <br /> " <br /> Well Destruction ❑ Welt Diameter <br /> Depth ' ' 'Fiiler,MMaterial & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR�I•ADDITION i I DESTRUCTION Mo septic system permitted if public sewer is -} <br /> 4 available within 200 feet.I <br /> { F <br /> Installation will serve: Residence��" 'Commr ercial Zother <br /> 'Number of living units: Number of bodroorTIS <br /> Character of soil to a dept feet-feet: - W Water table depth <br /> SEPTIC TANK L�1 Type/Mfgcapacity—A No. Compartments <br /> r, <br /> PKG. TREATMENT PLT. ❑ Method-.of Disposal <br /> Distance:to nearest: Well,��lFoundation Property Lined--f k <br /> LEACHING LINE Ll No. & Length of lines Total length/sixa - <br /> FILTER BED LI Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS L7 Distance to nearest: Well foundation Property Line t' <br /> DISPOSAL PONDS ❑ � ' <br /> I hereby cenify 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 cenifies the following: "I certif;that in the performance of the work for which this permit is issued, I shall not I� <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 /> f 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 ust call or all r aired insPections. Complete drawing on reverse side. <br /> f� I Title: `_ Date: � <br /> Signed r <br /> 71j, <br /> DEPARTMENT USE ONLY f�Application Accepted by /�D <br /> .r/I ate �'r�- Area L1 <br /> Date Final Inspection by A AA� Dat.4 a —76 l <br /> Pit or Grout Inspection byT l,, A <br /> E Additional Comments <br /> Applicant - Return all copies to. San Joaquin County Public Health <br /> Services, Environmental Health'Permit/Services <br /> 1 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> 4t` FEE AMOUNT DUE AMOUNT REMITTED + K Hr' ' RECEIVED BY DATE PERM17'N0. <br /> INFO <br /> a EH 13.24IREV.t1n5f t3< '� 3, � j off ' /2�lC� <br /> EH 7I-2a +E?' 1 b + h <br />