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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 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FR M DATE_-1S_§_UED <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 /> 1 <br /> �( Job Address Aag wile. City Lot Size/Acreage <br /> � II <br /> Owner's Name t Address PhoneJJ�� <br /> 1f Contfactor Address .- License NoJfii Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> OTHER C3 itoring Well U <br /> DISTANCE TO NE �FO <br /> PTIC TANK SEWER LINES DISPOSAL FLD. OP. LINE <br /> ONAGRICULTURE WELL OTHER PITS/SUMPS <br /> INTENDED USE ,TYPE OF WELL EM AREA CONSTRUCTIO IFICATIONS <br /> L1 Industria! 7., B © Manteca Dia. Excavation Dia. of Well Casing <br /> fa Domestic/Private ❑ Tracy ype o Specifications <br /> i'I Public Ia Depth of Grout Sea Type of Groui I irrigation l I Eastern Surface Seal Installed by <br /> Repair Work Done U of Pump H.P. State Work Done _ <br /> Well Destructio ❑ Well Diameter Sealing Material S Depth <br /> Depth Filler Material S Depth <br /> 1. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I I DESTRUCTION (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 ❑, No. & Length of lines Total length/size ` <br /> F <br /> FILTER BED C!s Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 applic t ust call r all quire ins tions. Complete drawing on reverse side. <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY c� 7 <br /> Application Accepted by Date k 1 Area Ll <br /> 9 <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant – Return all copies to: San Joaquin County Public Health <br /> —Services, Environmental Health-Permit/Services <br /> 1601 E. Haselton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> i <br /> FEE AMOUNT DUE AMOUNT REMITTED I CK RECEIVED BY DATE PERMIT'NO, <br /> INFO CASH <br /> H 14.2IREV.,,Ns,�� -1. -� -� Ito I <br /> EH 14•26 V- 16.LI Iq I <br /> k <br /> f <br />