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APPLICATION FOR PERMIT <br /> i <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> REMIT EXPIRES_ ]. YEAR_FROWDATE 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 Ordinance No. 549 and 1$62 and the Rules and Regulations of San <br /> Joaquin County, }blic Health Services. <br /> ►^Job Address r 2- Y �11�� City Lot Size/A re e -5f, <br /> �,J Owner's;aL <br /> Q <br /> Y Address 3c Z�- Phone <br /> \Conlraci - Address License No. Phone ' <br /> f <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLA MENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYST REPAIR 0 OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LI 5 DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTU ELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA 0 STRUCTION SPECIFICATIONS <br /> Industrial D Open Bottom C] Manteca Dia. Well Excavation Dia. of Well Casing <br /> C7 <br /> Domestic/Private Cl Gravel Pack ❑ Tracy Type o Casing Specifications <br /> I'l Public 1:1 Other Cl Delta Depth of rout Seal Type of Grout <br /> I I Irrigation Approx. Depth I 1 Eastern Surface Se Installed by r <br /> Repair Work Done U Type of Pump P. State Work Hone <br /> Well Destruction ❑ Well Diameter Sealing Material & D th + <br /> Depth Filler Material & Depth 4 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION I (No 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: 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 D No. & Length of lines Total length/size <br /> FILTER BED EI Distance to nearest: Well Foundation Propeny 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 o►sub-contracting signature <br /> certifies the foil Ing: "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 C i rnia." <br /> The applicants call for i ed inspections. Complete drawing on r rse side. <br /> Signed5! <br /> � Title: Date: <br /> 4-9-30 <br /> EP T USE ONLY <br /> Application Accepted by "`- - Date —� �� Area <br /> Pit or Grout Inspection by Date Final Inspection by Date 2- t <br /> Additional Comments: I` <br /> i <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 /> FE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMl7'N0. <br /> INF / SH <br /> I <br /> a EH i3-24{REY.t/R51 �� <br />