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1 <br /> F <br /> 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 /> REMIT EXPIRES 1 YEAR FROM DATE ED <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 catapliance with San Joaquin County Ordinance No. 549 ag,d 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address Cit . Lot Size/Acreage <br /> Owner's Name Address Phone 's" 7 <br /> Contractor Address L/ License <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT F DESTRUCTION o Out of Service We11 0 <br /> _ PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER 0 Monitoring Well C7 <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 /> 1-1 Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Wail Casing <br /> [I Domestic/Private D Gravel Pack 0 Tracy Type of Casing Specifications <br /> I Public Cl Other i-1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation — Approx. Depth I i Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done _ <br /> Well Destruction 0 Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION It< DESTRUCTION I I INo septic system permitted if public 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: e Water table depth �- <br /> SEPTIC TANK 0 Type/Mfg Capacity No, Compartments <br /> PKG. TREATMENT PLT, 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 139—No. & Length of lines f, Total length/size <br /> FILTER BED (-I Distance to nearest: Well Foundation C}20 ' Property Line <br /> SEEPAGE PITS I&---Depth r�� r Size�� � _ Number <br /> SUMPS H Distance to nearest: Well Foundation s ' Property Line ° <br /> DISPOSAL PONDS 0 <br /> I hereby certify that I have prepared this application and that the work wilt 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 California." <br /> The applicbqkmust call for all requir ins, ctions. Complete drawing on reverse side. <br /> Signed _ _-�-- Title: Date: <br /> FOR EPARTMENT USE ONLY <br /> Application Accepted by _T Date f Area <br /> or Grout Inspection by ��� Date) '� Final Inspection by c 'Yf Date C `� <br /> Additional Comments: <br /> Applicant - Return a,11 copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201CK <br /> a� <br /> FEE AMOUNT DUE AMOUNT REMITTED CRECEIVED BY DATE PERMIT NO.EH � <br /> INFO I )AH Su <br /> + EH�,{.2B SREV,i i n51 O C7 r�f 4�T 3 � <br />