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APPLICATION- POR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 3 ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 Ordinanc No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. /J <br /> Job Address /, City �j�= _ Lot Size/Acreage <br /> Owner's Name Fi �P, Address Phone <br /> Contractor 41C>�AZUddress License N.-,->,gPhone a' <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR �Z OTHER ❑ Monitoring Well L7 <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 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 1.1 Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications <br /> I"1 Public Cl Other n Delta Depth of Grout Seal Type of Grout <br /> ItIlCIrrigation _.Approx. Depth V Eastern Surface Seal Installed by <br /> epair Work Done Type of Pump H.P. �{�_ State Work Done Q <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth \ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I Mo septic system permitted if public sewer is \ <br /> available within 200 feet.) r <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: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total•length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 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 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 ap �Callfo,all required i ctions. mplete drawing on reverse <br /> �side. oe <br /> Signed G Title: __ 2 f' s' Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by 2 <br /> Date Area <br /> Pit or Grout Inspection by Date Final Inspection by .� ' Dat <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 RECEIVED BY GATE PERMIT'NO. <br /> INFO CASH <br /> + EH 13-24 IREV. /x slVD <br /> EH 11.26 " / I <br />