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n <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> J ENVIRONMENTAL HEALTH DIVISION I <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O SOX 2009, STOCKTON!, CA 95241 <br /> EXP RES 1 YEAR FROM D ED <br /> I (Complete iia 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 .*aith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San i <br /> Joaquin County Public Health Services. <br /> Job Address City5lO Lot Size/Acreage <br /> - _ ) <br /> Owner's Name Address Phone <br /> ContractorAddress License No. Phone 1 u <br /> TYPE OF W LL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ out of Service Well <br /> PUMP INSTALLATION ❑ SYSTEM-REPAIR C OTHER O 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 /> I-) Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> [7 Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications � <br /> ('1 Public 1-1 Other n Delta Depth of Grout Seal Type of Grout -9 <br /> I I irrigation _Approx. Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done L7 Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material 8 Depth <br /> Depth * Filler Material fL Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION INo septic system permitted if public sewer is <br /> vailable within 200 feet.) 11� <br /> Installation will serve: Residence XF1 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. ❑ a 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 C-1Distanceto{nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> .t <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ `-I <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 compansa- <br /> tion laws of Califo N <br /> The applicant u r uir inspections. Complete drawing on rewm side. <br /> Signed X Title: Date: I <br /> OR RTMENT USE ONLY <br /> Application Accepted by 0KDate^L`6� - Area <br /> Pit or Grout inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies toC 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 MOUNT DUE UNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH �/� R <br /> 77 <br /> . EH 13-24IREV.1/n5f !�Z r. `- V <br /> CH 114.28 <br />