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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 O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FRAM DATE ISSUED <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. <br /> r f <br /> Job Address City Lot Size/Acreage `L <br /> Owner's Name Address 57D Phone <br /> Contractor---a= AddressLicense No. 7Phone�6L'S��7 <br /> TYPE OF WELL/PUMP: NEW WELL © WELL REPLACEMENT ID DESTRUCTION o Out of Service Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER D Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> f � <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ' <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ` <br /> f_-] Industrial 0 Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private Cl Gravel Pack 17 Tracy Type of Casing Specifications <br /> f' <br /> Il Public Ll Other _ n Delta Depth of Grout Seal r t _ Type of Grout <br /> I I Irtivation" Approx. Depth I I Eastern ;Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Dona _ <br /> Well Destruction 0 Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.l <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: AZIFI���'`' "'� - Water table depth <br /> SEPTIC TANK. O Type/Mf! Capacity-= No. Compartments <br /> PKG. TREATMENT PLT. D Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE D No. & Length of lines �/7 Total length/size <br /> FILTER BED C! Distance to nearest: Well �/ Foundation _ e Property Line <br /> SEEPAGE PITS 1 1 Depth .___ Size Number <br /> SUMPS LI Distance to nearest: Well 106^_ Foundation /400`7^ Property Line <br /> DISPOSAL PONDS D <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 /> Horne owner or licensed agent's signature certifies the following: "I cetify 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." 11 1 ' ` <br /> The applicant rn, all for al ed ins pe tions. Complete drawing on reverse side. +"f <br /> f <br /> Signed X Title: Date: <br /> FOR DEPARTMENT USE ONLY 9 <br /> pplication Accepted by x Rate �" ` Area <br /> Pit of Grout Inspection by Date Z `` Final inspection by Date l <br /> Additional Comments: <br /> R <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 CK RECEIVED BY DATE _ PERMIT'NO, <br /> INFO CASH '} <br /> . EH 13*2426 <br /> rinsr L l t3�1 `'�� 1l 1 <br />