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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, STtOCKTON, CA 95201 <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUE <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a pertait to construct and/or install the work herein described. _2pis <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of Sin <br /> Joaquin County Public Health/Services. <br /> Job Address Lot size/Acreage <br /> Owner's Name L Z &C2_aj, m+Address Phone <br /> Contractor -.—AddressT Z!kk License N41'5_�2;:E�Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C3DESTRUCTION LJOut or Service Well <br /> OTHER O Monitoring Well Li <br /> PUMP INSTALLATION 0 SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLU. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> r, Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> C] Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'i Public 1:1 Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —..Approx. Depth I I Easiern— -"'-SiirTSce Seal Ins(alled'by <br /> Repair Work Done U Typeof Pump H.P. State•Work Done <br /> Well Destruction ❑ Well Diameter Sealing fiateri►l,b Depth z <br /> Depth Filler Material i Depth -- r- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR IADDITION DESTRUCTION I I INo'sep6c system parmh1ed if public sower is <br /> ♦ available within 200-feet.) <br /> ,f <br /> Instagation will serve: Residence•,J..z 'Commerclat Other <br /> Number of living units: Number of bedrooms _ +. <br /> �„�ytr�u ,moi f •,' '__ RWater table d.epth <br /> Character of soil to a da th of 3 tear. �'�'""� _ <br /> SEPTIC TANK. d Type/Mfg '�'�- <br /> No. Compartments <br /> / Method of'Disposel <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest., Well foundahoft `Property Line <br /> LEACHING UNE No. & Length of lines 6� � Notal length/size <br /> FILTER BED 0 Distance to nearest: Foundation Property Line <br /> 1. <br /> SEEPAGE PITS I I Depth Size r Number r <br /> SUMPS D Distance-to nearest: Weil ' 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 t <br /> rules and ragulations 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 far which this permit is issued, t shell net <br /> employ any person in such manner as to become subject to workmen's compensation laws of Calif jContractor's hiring or stt'work ran's c signature <br /> canities 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 eompansa- <br /> tion laws of California." ` <br /> The applicant must call for all required inspections. Complete.drawing on reverse side, -A <br /> 'PepSigned X �� j Title: <br /> Date: <br /> F DEP ONLY <br /> Appticatlon Accepted by Date Area <br /> Pit or Grout Inspection by Date - Final Inspection by M a <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Hnvirotsmental Health Perait/Services <br /> 1601 E. Rat elton Ave., F 0 Box 2009, Stockton. CA 95201 <br /> FEE f j <br /> AMOUNT DUE AMOUNT REMITTED CASH RECEIVED fly OATS PERMiT'NO• <br /> INFO01 <br /> ,`• rT, <br /> . EH 12.24(REV.1/n 51 <br /> EH 14.20 <br />