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APPLICATION FOR PERMIT E r <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 Nrr�� Aa <br /> V <br /> P O BOX 2009, STOCKTON, CA 95201 �fV7�k <br /> PEMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) �. <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein desc abed. This <br /> application is made in compliance with Ban Joaquin County Ordinance No. 5h9 and 1$62 and the Rules and Regulations of San I <br /> 1 <br /> Joaquin County Public Health Ser ices. j <br /> Jab Address City of Size/Acreage 1 <br /> a <br /> Owner's Name ` ddress Phone Zf <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 /> C] Industrial ❑ Open Bottom ❑ Manteca Dia.'of Well Excavation Dia. of Well Casing <br /> f7 <br /> Domestic/Private Cl Gravel Pack C] Tracy Type of Casing Specifications <br /> Public is Other 171 Delta Depth of Grout Seal Type of Grout <br /> I <br /> i I Ifrigalion _Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTIOI iNo septic system permitted if public sewer is <br /> vailable within 200 feet.I \ <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 D No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Wall Foundation Property Line <br /> SEEPAGE PITS I I Depth Size _ Number <br /> SUMPS Ul Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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, 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 no, <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 ap. keant must call for all required inspectionsComplete drawing on reverse side. <br /> Signed a Q"Off" 3 —_ Title: - Date: <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by �A Date Area <br /> Pit or Grout Inspection by QQData Final Inspection by <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Persalt/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> CK 44 <br /> INFE AMOUNT DUE NT REMITTED CASH RECEIVED BY DATE PERMIT'NOO, <br /> Ell Ek 11224 lAEV.I/A5l C.�� • � ��3�� ���z 6+ <br />