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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. y� <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-342 <br /> 0 AUG ? a! �� <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> NVIIRONMENTAE HEAL h <br /> PERldIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT SERVICES <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 <br /> Health Services. <br /> Job Address City Lot Size/Acreage <br /> - <br /> LZ <br /> Owner's Na ddres Pff <br /> hone� ` <br /> Contract �s / L� License No. Phone w <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACE NT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATI SYSTEM REPAT�� OTHER ❑ Monitoring Well <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 /> n Industrial Cl Open Bottom ❑ Manteca Dia. of Welt Excavation Dia. of Well Casing <br /> mestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'1 Pubfic f_l Other IF] elt Depth of Grout Seal Type of Grout <br /> -- <br /> I Irrigation Approx. I I Eas rn Surface Seal Installed by <br /> Repair Work pone [J Type of Pum P. to e or e, <br /> Well Destruction ❑ Well Dia tet / Sealing Material & Depth [/jamb <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTION I I SNo septic system permitted if public sewer is <br /> � <br /> Installation will serve: Residence_ Commercial_ Other available within 200 feet.) <br /> Number of living units: Number of bedrooms rye, <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg <br /> PKG. TREATMENT PLT. C} Capacity No, Compartments W <br /> Method of Disposal <br /> Distance to neatest: <br /> Well Foundation Property Line <br /> LEACHING LINE D No. & Length of lines Total length/size <br /> FILTER BED Q Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS <br /> it Depth Size Number ? <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <br /> 1 hereby certify shat 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 manner as to become subfect 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 applicaPIT ust c 11 1 required i�nsp(e�ctiti/ons. Complete drawing on erse si <br /> Sign Ti . �� 1C " <br /> Date: <br /> R DEP ENT USE 0 <br /> Application Accepted by ��24L �� <br /> Date Area <br /> Pit or Grout Inspection by <br /> Date Final Inspection by.__ L�-�Z pate <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 REMITTEDCK <br /> INFO ASH RECEIVED BY DATE PEAMIT'NO, <br /> + EH 13-24(AM <br /> EH 4-26 <br />