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F k 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 O BOX 2009, STOCKTON, CA 95201 <br />{ RES 1 YEAR FROM D TE ED <br /> (COmplete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. T <br /> application is made in cor�,liance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations <br /> f Joaquin County Public Health Services, his <br /> ns of San <br /> Job Address <br /> City Lot Size/Acreage <br /> Owner's Name .-.• - <br /> Address <br /> ' <br /> Contractor �, C, <br /> Phone <br /> Address <br /> TYPE OF WELL/PUMP: NEW WELL ❑ License No.3ya` �j y Phone <br /> WELL REPLACEMENT LJ DESTRUCTION Cl Out of Service Well ❑ <br /> PUMP INSTALLATION <br /> DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR C7 OTHER © Monitoring well <br /> ---•�-„ SEWER LINES �� DISPOSAL FLD. <br /> FOUNDATION AGRICULTURE WELL -- PROP. LINE <br /> INTENDED USE TYPE OF WELL ---� OTHER WELL-. PITS/SUMPS <br /> PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ! ] Industriai ❑ Open Bottom ~� <br /> O Manteca Dia. of Well Excavation ' <br /> �) <br /> Domestic/Private 0 Gravel Pack Q Tracy T Dia. of Well Casing <br /> f I Delta <br /> f'1 Public 1-1 Other Type of Casing Specifications <br /> I ! Irrigation � � Depth of Grout Seal <br /> —...Approx.Type of Pump Depth ern Surface Seal Installed by Type of Grout <br /> Repair Work Done (] 2 - - <br /> 5",22—E"E. H.P. - _ rr <br /> Well Destruction El Well Diameter Sealing Material & Depth State Work Done w <br /> Depth Piller Material & Depth <br /> TYPE OF SEPTIC WORK; NEW INgTALLATION I ) REPAIR/ADDITION F ION I I (No septic system permitted if public sewer is <br /> Installation will serve: Residence— Commercial available within 200 feet.) <br /> Number of livingunits: -- Other <br /> Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK. 13 Type/Mfg Water table depth <br /> PKG. TREATMENT PLT, C) '.- ' Capacity. No. Compartments <br /> Distance to nearest; Method of Disposal <br /> Well F Foundation �j <br /> Property Line f a <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BED total length/size <br /> �7 Distance to nearest: Well Foundation ► <br /> Property Line <br /> SEEPAGE PITS ( ) Depth <br /> SUMPS Size Number <br /> Ll Distance to nearest; Well Foundation <br /> DISPOSAL PONDS 1) --- —� Property Line a <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 fofiowing; "I certify that in the performance of the work for which this permit is issued, 1 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: 1 certify that in the pe ormance of the work for which this permit is issued, I shall employ <br /> tion laws of /California." P Y persons subject to workman's compensa- <br /> The applica` t must call fo all required s ctions. Complete drawing o reverse side. <br /> g : CSA <br /> Si ned <br /> Title ,LC�._ )rte /S <br /> Date <br /> FOR DEPARTMENT USE ONLY I <br /> Application Accepted by — <br /> Data Area M <br /> Pit or Grout Inspection by f_ <br /> Additional Comments: <br /> Date— Final Inspection by l s <br /> ' <br /> I <br /> Applicant - Return all copies to: San Joaquin County Public Health F <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE <br /> PERMIT N0. <br /> EFi 13.21(REV,1/N51 J.(�(� <br /> EH 1120 <br /> 41_( 30 <br /> P <br />