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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)46$-3420 <br /> P O BOR 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE SSUED <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 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> w t CityZ__JC4�14t Size/Acreage Z 2 C3Job Address <br /> Address Phone <br /> Owner's Nam <br /> Contractt Cc Address _ C_(�(r License NdZ�Uy Phone <br /> TYPE OF WELL/PUMP: NEW WELL C1WELL REPLACEMENT [] DESTRUCTION ❑ Out of Service Well LI <br /> PUMP INSTALLATIONX SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK / SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL-- PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> C1 Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications <br /> Ul Public C.1 Other fl Delta Depth of Grout Seal Type of Grout <br /> X(rigation _._. Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump f'ZkJaLuF_ H.P.r,/I.-) State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I 1 INo septic system permitted if ptiblic sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ 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 Ll 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 C / rnla." ; <br /> Thai m st for II required ins cti s. Co late drawing on verse side.,.call <br /> . ISigned ! Title: Date: <br /> / FOR DEPARTMENT USE ONLY C� <br /> Appfication Accepted b Date — `3 Area <br /> Pit or Grout Inspection Date Final Inspection by �� �-^L� Date <br /> Pit or or Grout lnspection� d d <br /> Additional Comments: — <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, 'Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED H RECEIVED BY DATE PERMIT'NO. <br /> rcyr INFO <br /> r EH 13-24 IAEV.r/n 51 <br /> EH A-2a <br />