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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 /> EXP RES 1 YE RgROM IDAT <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 /> City ��3•I Lot Size/Acreage <br /> Job Address ��� <br /> L.�.�Zl4JN1 3 J /V• J-� Phon 77771 <br /> Owner's Name Address <br /> Contractor <br /> Address License No.� Phone_ <br /> WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ Out of Service Well [3 <br /> M REPAIR ❑ OTHER © <br /> PUMP INSTALLATION ❑ <br /> SYSTEM Monitoring Well ❑ <br /> DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES --- PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL - <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Type of Casing Specifications <br /> [I Domestic I Private ❑ Gravel Pack ❑ Tracy Type of Grout <br /> f'1 Public l f 1 Other) F1 Delta Depth of Grout Seal <br /> I I Irrigation_ %, Depth,'Dep ht l I Eastern, Surface Seal installed by <br /> H P State Work Done_ <br /> Repair Work`.Done i❑k Type of PumpSealing Material & Aepth <br /> Well Destruction ❑ Weil Diameter Filler Material & Depth F <br /> Depth <br /> TYPE OF SEPTIC WORK: ,NEW INSTALLATION I I REPAIRIADDITION I ] DESTRUCTION (Nailablelw thin 200 c system permitted it public sewer is <br /> \ ' <br /> F Installation will server`Residence Commercial her <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ .Type/Mfg <br /> Capacity Z�aT No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Property Line <br /> jDistance to nearest: Well Foundation <br /> LEACHING LINE C1 No. & Length of lines Total length/size <br /> i' Property Line <br /> FILTER BED Cl Distance to nearest: Well Foundation <br /> g? <br /> SEEPAGE PITS 11 R Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation _ Property Line <br /> DISPOSAL PONDS ❑ �' <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 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 nner ,as to become subject to workmen's compensation laws of California." Contractor's hiring or sub contracting signature <br /> certifies the following: "!c rti that in the performan for which this permit is issued, I shall employ persons subject to workman's compensa <br /> ti of California." <br /> T pp ca I in tions. Complete drawing on reverse side. ,+ ed <br /> t <br /> Signed <br /> Title: <br /> Date: _ — <br /> a F USE ONLY <br /> • ,Date Area <br /> Application Accepted by <br /> Date Final Inspection by Date-7 C5 <br /> Pit or Grout Inspection by <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 (��1 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"ND. <br /> we INFO <br /> . ev <br /> EH 13-24 IREV. n sl <br /> EH A-26 <br />