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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 BOR 2009, STOCKTON, CA 95201 <br /> ZKIJ EXPIREEXPIREN 1 YEAR FROM DA <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 Servs. 7N <br /> .'�• � _ City Lot Size/Acreage <br /> kJobAddress ��/d7er's Name <br /> Address z" ' Phone' Address License No. Phone <br /> tractor <br /> TYPE OF WELL/PUMP: „ NEW WELL ❑ WELL REPLACEMENT Cul DESTRUCTION Out of Service We11 ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> OTHER ❑ Monitoring Well C1 <br /> DISTANCE TO,N,EAREST:,SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> r' .FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> k INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> r Cl Industrial ❑ Open Bottom ❑ Manteca pia. of Well Excavation Dia. of Well Casing <br /> f.l Domestic)Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'I Public Cl Other C1 Delta Depth of Grout Seal Type of Grout <br /> I I Eastern f Surface Seal Installed by <br /> I ! Irrigation _Approx. Depth <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> "v <br /> Well Destruction D Sealing Material & Depth Well Diameter <br /> Depth Filler Material & Depth ` �J <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I <br /> DESTRUCTION I i available et'w Thin 200 permitted tif public sewer is (- , <br /> t `� <br /> Installation will serve: Residence— Commercial_ Other <br /> t <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> 5 SEPTIC TANK CI Type/Mfg" Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ I Method of Disposal <br /> f Distance to nearest: Well Foundation Property Line <br /> 1 <br /> '-,"LEACHING LINE ❑ kNo. 8 Length of lines Total length/size <br /> FILTER BED El-Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS Ci Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS CD :c <br /> at the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application and th <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 /> cartifies the following: "I certify that in the rtormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of Calif rola." <br /> The appli mu t for all requ"re plate drawing on Jeu@rse side. �Q <br /> Signed X Title: Date: .c-f`� ZZ'�b <br /> .o ARTMENT USE ONLY <br /> M.�.. '` �- � 1 <br /> Application Accepted by Date Area <br /> T <br /> Pit or Grout Inspection by Date Final Inspection by Data <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 CK 8 ASH RECEIVED BY DATE PERMIT N0. <br /> INFO ---- <br /> EH 3-24 �O`f2(7 �ra 'oo Y57 <br /> EH t <br /> 4-26 <br /> I <br />