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ii <br /> 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 /> nFuuTm $gpIRES 1 YEAR FR M A E � <br /> (Complete in Triplicate) <br /> describe <br /> work <br /> in <br /> Application is hereby made�to San Joaqvith in SanCJoatuinor a permit County Orditnancenstruct No. 549&ando1862atall and theeRules endeRegulationsdof Sans I! <br /> application is made in compliance vith San q <br /> Joaquin county Public Health Services. <br /> Lot Size/Acreage <br /> City <br /> Job Address " xti le �y � _ <br /> ' Phone 1 <br /> Address'- "''� '• �, <br /> Owner's Name <br /> Address <br /> ContractorWeli <br /> _.. WELL REPLACEMENT ❑ DESTRUCTION ❑ Out'of ServiVgice Well ❑' <br /> I7YPE OF WELL/PUMP! NEW WELL ❑ OTHER I 1 LT <br /> PUMP INSTALLATION D SYSTEM R C7 <br /> M <br /> SE ER LINES DISPOSAL FLD. PROP. LI <br /> I DISTANCE TO NEAREST: SEPTIC TANK I OTHER WELL PITS/SUMPS ya FOUNDATION AG CULTURE ELL # <br /> I i <br /> xaNTENDED USE TYPE OF WELL PROBLEM A EA ONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> }(7 Industrial D Open Bottom ❑ Manteca ".Oia-"of Well Excavation — y <br /> T ;e of Casing Specifications.. tI` <br /> sEI.Domestic/Private ❑ Gravel Pack ❑ Tracy yp g <br /> I'l Public _ Cl Other <br /> Cl to Depth of Grout Seal <br /> Type of Grout , <br /> I I Ini{�ation" <br /> .Approx. Depth - Eastern Surface Sedl Installed by <br /> of Pump H.P. State Work Dane <br /> y Repair Work Done L7 Type • °" <br /> Seali Material &Depth <br /> R Well Destruction ❑ Well Diameter Filler Material is Depth - 11. <br /> `` Depth <br /> I TYPE OF SEPTIC"WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION 4 I (No s6peiwthinkm emitted if puli <br /> bc.sewer is �( <br /> feet <br /> ` Installation will serve: Residence—.. commercial— Other 4 <br /> t ( Z) �r N <br /> Number of living units: Number of bedrooms Water table depth{ " r"3 <br /> f Character of soil to a depth of i feet: L <br /> SEPTIC TANK. D Type/Mfg `� Capacity r7r7--; "No. Compartments � <br /> PKG. TREATMENT PLT. ❑ f Method at Disposal ' <br /> Distance t no B �arest: Well ,.Foundation Property Line t <br /> k <br /> k - 7 al length/size <br /> ,LEACHING LINE L1 No. & Length of-lines W <br /> l I FILTER BED ❑ Distance to nearest: Well�_ Foundation Property Line <br /> a �• f _ Number <br /> SEEPAGE PITS 11 Depth Size <br /> SUMPS LI Distance to nearest: Well <br /> Foundation Property Line fes... <br /> DISPOSAL PONDS ❑ <br /> ork will be done accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that i have prepared this application and that the.w <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 ontr ued,�l shell not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring <br /> 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'�sr,abmpensa- <br /> k <br /> tion laws of California." <br /> The applicant st call for al' quirad ' speations. Complete drawing on reverse side. <br /> — Date: <br /> Signed Title: - <br /> ft t <br /> 41,11 <br /> iNEfUT USE ONLY <br /> 1Application Accepted by <br /> DateArea <br /> to incl Inspection byor Grout Inspection byate- `� t <br /> ((Additional Comments: <br /> i Applicant Return a.11 copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services i t <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 9.5201 <br /> t FEE MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO 11 <br /> t . EH 13-21 tPEY. Q•t7"]C Q <br /> EH14-25 <br />