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s <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 O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES1 YEAR FROM DATE ISSUED <br /> Veto/8'ran <br /> �°� (Complete in Triplicate) <br /> Application is hereby 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 end 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address City. Lot Size/Acreage <br /> ALL <br /> in a <br /> Owner's Name Address � Phone <br /> Contract or �� __Address t�G, )cense No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION 0 Out of Service Well ❑ <br /> t Monitoring Well <br /> PUMP INSTALLATION ❑ %SYSTEM REPAIR ❑ OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. UNE <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 /> qDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'I Public I-] Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation — Approx. Depth I I Eastern Surface Seat Installed by <br /> Repair Work Done %J Type of Pump_. H.P. . �� Stat rk Done <br /> Well Destruction ❑ Well Diameter Sealing,Material & Depth <br /> Depth Filler Material 515epth t <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I }-DESTRUCTION I I INo septic system permitted if public sewer is <br /> + available within 200 feet.) Q <br /> Installation will serve: Residence T Commercial_ Other , <br /> Number of living units: Number of bedroomsY, <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. ❑_. . ---.�Methoo <br /> d of Disposal <br /> Distance to nearest: -Well Foundation _ ry Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> . . r - <br /> SEEPAGE PITS i I Depth' Size- Number <br /> SUMPS 0 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ y <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 manneii'as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify#'hat 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 applicant must call foII required inspections. Complete drawing on reverse side. <br /> Signed X Title: —r _- ----- Date: <br /> F DEPARTMENT USE ONLY <br /> Application Accepted by Date Area Y <br /> Pit or Grout Inspection by Date Final Inspection by Datc7 <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 /> EEE AMOUNT DUE AMOUNT REMITTED I CK RECEIVED BY DATE PERMI7'N0, <br /> INFO CASH <br />' <br /> El 13.2- ,iK51 a"S <br /> k EH 14-26 111 �-'\ <br />