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APPL LCAT I ON FOR PERIL I T <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> V►- p{a„t P O $OX 2009, STOCKTON, CA 96201 <br /> PERMTT EXP DVQ 1 YEAR FROM DAT Eb <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 © c <br /> City (/`bat Size/Acreage <br /> Owner's NameS' <br /> a..Address <br /> Phone <br /> Contractor �� <br /> � Address�� <br /> TYPE OF`WELL/PUMP:- License No Q Phone <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION C7 SYSTEM REPAIR <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ Monitoring Well �� <br /> --�w SEWER LINES --�.�� DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL <br /> OTHER WELL PITS/SUMPS <br /> INTENDED USE �, TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> NDomestic/Private ❑ Gravel PackDia. of Well Casing <br /> L7 Tracy Type of Casing <br /> �. H Publice�C7 Other �t -, n Delta Specifications <br /> I f Irrigation i�`_ depth of Grout Seal <br /> Approx. DeptType of Grout <br /> h I Eastern <br /> Repair Work Done r Surface Seal Installed by <br /> Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth -- . Filler Material & Depth _4 <br /> TYPE OF SEPTIC WORK _NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION f I 1 4 septic system permitted if public sewer is <br /> l <br /> Installation will serve: 'Residence Commr ficial_ available within 200 feet.) <br /> Other <br /> Number of living units: ` Number of bedrooms x--- � <br /> r. <br /> Character of soil to a depth of 3 feet: ' <br /> SEPTIC TANK. Water table depth <br /> ❑ Type/Mfg Capacity— <br /> No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> t <br /> Distance to nearest:- Well. Method of Disposal <br /> Foundation, + <br /> - _____ . _ Property Line <br /> LEACHING LINE ❑ No. & Length of lines• A. " o <br /> Tonal length/size <br /> FILTER BED <br /> C7 Distance to nearest: Well Foundation_ <br /> Property Eine <br /> SEEPAGE PITS <br /> i I Depth Sire Number J <br /> SUMPS LI Distance to nearest: Well <br /> DISPOSAL PONDS p Foundation 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 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 smplo <br /> tion laws of California." y persons subject to workman's comp nsa <br /> The appli must all f�afluired i ctions. mplete rawing on r ide. <br /> Signed X � <br /> Title: I <br /> Date: <br /> I�� <��ILQ.EPARTMENT USE ONLY � <br /> Application Accepted by <br /> Date Area <br /> Pit or Grout Inspection by Data <br /> ---—. Final Inspection by Data <br /> Additional Comments: <br /> Applicant - Return an 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 MOUNUE AMOUNT REMITTEp CK <br /> INFCASH RECEIVED BY DATE <br /> EPEl)NO] <br /> EH 13-24 IREV.I Is 51 <br /> EH;I-2e 5TD <br />