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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 /> POWIT XP RES 1 YEAR , ROM DATE <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 Health Services. <br /> Job Address ttA City I Lot Size/Acreage 0`�� <br /> L <br /> Owner's Name AddressC!����.� e_- V7F0. G'cpKone <br /> Contractor Address ® License N . Phone Y� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION C] Out of Service Well ❑ <br /> PUMP INSTALLATION C] , SYSTEM REPAIR OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO, 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 /> C] Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> Il Public CI Other ❑ Delta Depth of Grout Seal <br /> Type of Grout <br /> IKIrrigation —Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done [ Type of Pump H,P. State Work Don • <br /> Well Destruction p Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAMIADDITION i I DESTRUCTION I 1 INe septic system permitted if public sewer is <br /> Installation will serve: Residence— Commercial_ Other available within 200 feet.) <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. ❑ <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size f <br /> FILTER BED ❑ Distance to nearest: Well Foundation-�.� Property Line <br /> SEEPAGE PITS [ I Depth Size Number <br /> SUMPS LI Distance to nearest: well Foundation <br /> DISPOSAL PONDS ❑ –�- Property Line <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 litensed 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 e <br /> tion laws of California."" mploy persons subject to workman's comps a- <br /> TheaZnmusallfor all ed ins coons. mplete drawing se side. ' <br /> Signed X Title: e d ' <br /> Date: <br /> FOR DEPARTMENT USE ONLY r <br /> Application Accepted by Date "� OAr G <br /> Pit or Grout Inspection by Date— Final Inspection by <br /> Date <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 <br /> INFO CASH RECEIVED BY DATE EPE1MIT'NO. <br /> a EH 13.24 IAEV. n 51S.(�O +- �J EH54-2stffj <br />