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APPLICATION FOR PERMIT v <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)4683420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PFJMIT EXPIRES 1 YEAR FROM DAT ED <br /> (Complete, in Triplicate) <br /> Application is hereby made to San Joaquin County far a permit to construct and/or install the work herein described. This <br /> application is trade 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 <br /> , g" 0 Al City _� Lot Size/Acreage <br /> � <br /> Owner's Name Address 7 +3 Phone `f&3^s g <br /> Contractor 6� I-P Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well D <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <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 /> C-1 Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> D Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> F1 Public 1:1 Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _ Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done v Type of Pump H,P. State Work Done <br /> Well Destruction ❑ <br /> Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION l I DESTRUCTIONINo septic system permitted if public sewer is <br /> - ailable within 200 feet.) <br /> Installation will serve: Residence— Commercial�.,. Other'' ' /� 1 yo <br /> (Number of living units: Number of bedrooms U I <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. 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> th/size <br />� LEACHING LINE, Cl Na. & Length of lines Total len g <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> I <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, an <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 /> I employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall empjoy erso su j ct to workman's compensa- <br /> tion laws of California." <br /> The applicant mZk�lw <br /> all for all re wired in cti s. Complete drawing on reverse side. <br /> Signed Title: Date: 42 F <br /> v <br /> FOR DEPARTMENT USE ONLY c� <br /> Application Accepted by Date `� Area <br /> Pit or Grout Inspection by Data Final Inspection by Date <br /> r f } <br /> I <br /> Additional Comments: / 1a `/d/a A <br /> t o,�t, <br /> Applicant - Return all copies to. San Joaquin County ?-U-=c Healtri <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2909, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED By DATE PERMIT NO. <br /> INFO CASH <br /> r EH 13-211REv.1"5l <br /> EH 14.25 <br /> t <br />