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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 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE_ IS5UMI <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 /> J uin County Public Health Services. <br /> N I <br /> Job AddressF it 1 City IV Lot Size/Acreage <br /> }Owner's Name Address Phone D <br /> Contractor 5�1� Address < b6✓ License hlo. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> Monitoring Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ❑ <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 /> F1 Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> i <br /> [-] Domestic/Private L1 Gravel Pack 0 Tracy Type of Casing Specifications <br /> Il Public C] Other Cl Delta Depth of Grout Seal — Type of Grout <br /> I I Irrigation —.Approx. Depth l I Eastern Surface Saal l6stalled by <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction O Well Diameter Sealing Material & Depth <br /> Depth Filler Material 8 Depth'" _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION ) INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> N1, <br /> Installation will serve: Residence Commercial— Others <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 F <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> I LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Wall Foundation Property Line <br /> SEEPAGE.PITS.- I I'"Depth Size Number <br /> 1 SUMPS 0 Distance to nearest: Well Foundation Property Line <br /> I DISPOSAL PONDS ❑ <br /> l 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 /> I 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, t shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> XThe applicant must tali for all required inspections. Complete drawing on reverse side. <br /> Signed X Title: Date: <br /> �ERAART�MENT�USEON�LY Application Accepted by �,t, Datey Area <br /> i Pit or Grout Inspection by Date Final Inspection by Date <br /> j Additional Comments: — <br /> Applicant — Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services `�n <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 `" <br /> a, <br /> ' FEE AMOUNT DUE AMOUNT REMITTED I CK RECEIVED BY DATE PERMIT'NO. <br /> INFO /CCASS�H [� qty? <br /> . Eµ13-21(REV.t/145) t Q� C�� C./ 1 �•-- 46 7 7i �� R Lj�to <br /> EH t4.26 r <br />