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r <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 /> EXP RES -1 YEAR FRPM DAIR <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 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health 8 vice . <br /> Job Address City Lot Size/Acreage . <br /> l � I <br /> Owner's Name �AAd�ddress Phone <br /> Contractor Address y7� /{��ef <br /> _ License No .6_s'R X Phone 6 <br /> TYPE OF WEL /PUMP: NEW WELL © WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR d OTHER ❑ Monitoring Well <br /> I" DISTANCE TO NEAREST: SEPTIC TANK SEINER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T <br /> t INTENDED USE TYPE OF WELL PR08LEM AREA CONSTRUCTION SPECIFICAT104S <br /> i <br /> 0 Industrial D Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ["I Domestic/Private- ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br />! Il Public C] Other 11 Delta Depth of Grout Seal Type of Grout <br /> 11 Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done_ § <br /> Well Destruction ❑ Well-Diameter, Sealing Material b Depth <br /> k Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION (No septic system permitted it public sewer is <br /> E available within 200 feet. <br /> Installation will serve: Residence Commercial Other ry <br /> Number of living units: Number of bedrooms <br /> p <br /> Character of soil to a depth of Water able 3 feet: a t depth <br /> I SEPTIC TANK Type/Mfg Capacity No. Compartments <br /> k PKG. TREATMENT PLT. ❑ Method of Disposal <br /> I <br /> L _ Distance to nearest: Well Foundation Property Line <br /> ti <br /> .,LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL`PONDS D <br /> I hereby certify that l 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: "l certify that in the performance of the work for which this permit is issued, I shall not <br /> i 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 t Ifo a uired inspections. Complete drawing on raver side. <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY Q !� <br /> Appiication Accepted by ���' i-�. /�-1'� Date L v Area <br /> Pit or Grout Inspection by ) Date Final Inspection by�/ �� r's't� te� <br /> i <br /> Additional Comments: <br /> : <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., F 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> INFO } CA /+ /� <br /> + EH 13-24 IAEV.r/H 51 ^� a O d n/ y Jqd <br /> _16-0q <br /> 16/J✓� <br /> EH 4{xe CJ OOOY 6 C/ t <br />