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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)468--3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> REMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <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 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. L �3 arc <br /> Job Address �/ �/ r "-'�` ` • 'Cit Lot Size/Acreage �Cr _ <br /> Owner's Name `� ' /W Addresshone <br /> Contractor_.QC(.11AZ47r dU421&ddress License No, Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service We 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitorin L7 <br /> DIST! EPTIC TANK SEWER LINES DISPOSAL FLO. PROP <br /> FOUND AGRICULTURE WELL OTHER WELL S/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM A NSTRUCTlON E PECIFICATIO <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. o ation Pia. of Well Casing <br /> C:7 Domestic/Private 11-3 Gravel Pack 0 Tracy Type of Casin Specifications <br /> I'! Public (:I Other n Delta Oe Grout Seal Type of Grout <br /> I i Irrigation —,.Approx, Depth 11 Eastern Surface Seul Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction Sealing Material & Depth <br /> Depth Filler Material A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIR/ADDITION l I DESTRUCTION I I INo septic system permitted if public sewer is r <br /> available within 200 feet.), <br /> Installation will serve: Residence X Commercial— Other M <br /> J <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. � Type/Mfg G Capacity�40 No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of t AM � <br /> Distance to nearest: Well Mo _ Foundation 50 Properly Line <br /> LEACHING LINE �' No. & Length of lines Total length/size el <br /> FILTER BED 1 Distance to nearest: Well 5 ' Foundation Property Line �. <br /> SEEPAGE PITS i I Depth Size Number _ <br /> SUMPS Ll 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 mWWI dor d inspections. Complete drawing on reverse side, <br /> Signed X �� �Title: � Date: <br /> FOR €3EP RTfNENT USE ONLY f�T v G/. <br /> A���{{{p���---plication Acc tad by rrtt Date r/ Area <br /> Pil�or Grout Inspection by ! Date — TV <br /> Final Inspection by � � /�� '��Date�_ <br /> Additional Comments: r <br /> Applicant - Return all copies to: Sam Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTEDCASH <br /> INFO RECEIVED BY DATE PERMIT-NO. <br /> }} [� <br /> .00 <br /> IREV.�in51 �y Lil �""� .a� ��C.....) �ty �•��•�1 ������ <br />