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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 /> PEIMIT-MIRES 1 YEAR FROM DATE ISSED <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 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. J� <br /> Job Address 72,5' ,ry City Lot Size/Acreage <br /> Owner's Name AgQst &&bQF= A%dress Phone <br /> Contractor Address , _License No. Phone <br /> TYPE OF WELL/PUMP: NOW WELL X WELL REPLACEMENT M DESTRUCTION Cl out of Service Well ❑ <br /> PUMP INSTALLATiOK,� SYSTEM REPAIR D &j}, 7 Monitoring ell ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK r SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL -�' OTHER WELL l PITSISUMPS % <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATiO <br /> F] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'1 Public ,1.11Other n Delta Depth of Grout Seal Type of Grout Nf <br /> 1 1 Ir6oation t:9*4 Approx. Deptthh-' n( IIEEastern /Sr ace Seul Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done, <br /> Well Destruction 0 Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_____ Commercial Other <br /> Number of living units: Number of bedroor <br /> Character of soil to a depth of 3 feet: �, ,� -Water table depth <br /> SEPTIC TANK ❑ Type/Mfg p ) No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: ii�, Property Line <br /> LEACHING LINE ❑ No. & Length of lines _ otal length/size <br /> FILTER BED ❑ Distance to nearest: Property Line <br /> 4 <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS L] Distance to nearest: Well Foundation -. Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 applica mu a sal equi I s. Complete drawing on r v rsaside. <br /> Signed X Title: Date: <br /> FOEPAR7MENT USE OfV Y. (� <br /> Applica ' ccepted by � CAS!. � Rate `�^�r Area <br /> l <br /> Pit Grout apection by 1i ^ Date ZJ � Final Inspection by ' Date O U <br /> f <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin Court y Public Health0_lne 106 ��r <br /> Services, Environmental Health Permit/Setvices <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201FEE ` <br /> INFO AMOUNT DUE AMOUNT REMITTED C K RECEIVED BY DATE PERMIT NO. <br /> 3 <br /> . EH 13-24(REV,I/A SJ <br /> EH.4-2a <br />