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• � t P ' <br /> Z APPLICATION FOR PERMIT <br /> d SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HE'0-TH DIVISION <br /> 1601 T. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201, ' <br /> �4 <br /> 2T"IT 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 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 /> I Joaquin County Public--Health Services. <br /> F Job Address t �� City �� ( u Lot Size/Acreage _ aC <br /> Owner's Name Address Phone r <br /> -Contiaclor. __ _ Address License Not Phone <br /> TYPE OF WELL/PUMP: NEW WELL,❑ WiLEREPLACEMEPK ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ YSTEM R A1R ❑ T OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE E OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CO RUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca D' . of ell Excavation Dia. of Well Casing <br /> E-1 Domestic/Private ❑ Gravel Pack ❑ Tracy ype of sing Specifications <br /> C1 Public C7 Other 171 Delta Depth of G ut Seal _ } Type of Grout <br /> I I Irrigation _..Approx. Depth I I Eastern Surface Seal stalled by ! <br /> Repair Work Done 0 Type of Pump' State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Dep <br /> Depth Filler Material & Depth t <br /> TYPE OF SEPTIC WORK: NEW INSTAI:I ATION I I REPAIR/ADDITION �f DESTRUCTION 1 I,INo septic system permitted if public sewer is <br /> available within 200 feet.1 <br /> Installation will serve: Residence�,_.V17Commercial Other <br /> Number of living units: Number ofmbedr Pms <br /> j Character of soil to a depth of 3 feet: �.. <br />� • •„-.. .-.._.,. 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 /> y <br /> LEACHING LINE X No. & Length of lines J( sTotal length/size a X Ss <br /> FILTER BED Cl Distance to nearest: Well-40i— Foundation Property Line <br /> I 1 <br /> SEEPAGE PITS )(I Depth Sizeto _ Number <br /> SUMPS Ul Distance to nearest: Well 100 Foundation c3,0 f _ 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, 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, t shall not <br /> employ any person in such mariner 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 /> he applicant m s>yca o req c ' ns. Complete drawing on reverse side. 9 <br /> S+ ne¢ Title: 6 <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> jD Area <br /> Pit or Grout Inspection by rt Date Final Inspecl�l Date <br /> Addition Coomme`pt r <br /> Appli t` _ Re£ sl copies to: San Joaquin County Public <br /> Health <br /> ' <br /> t Services, Ehvironmental`Health Permit/S �r Ib �bk C <br /> 1601 E, Hazelton Ave., P 0 Box 2009, Stockton, CA 95201; <br /> FEE AMOUNT ptJE AMOUNT REMITTED CK r . <br /> INFO CASH RECEIVED aY DATE PERMIT NO, <br /> . EH13-21WV.CH 14-26 y/n !(((777}}} <br /> F - i <br />