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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)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> EMIT EXPIRES 1 YEAR FROM DAIE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to Sem Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. r <br /> Job Address City <br /> Got Size/Acreage <br /> p *� Phone J <br /> Owner's Name G Address i <br /> Contractor C_�/0—Address O License No.i Phone <br /> TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service WellI <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR ❑ OTHER ❑ Monitoring well [3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE ' <br /> FOUN ATION M AGRICULTURt'WELL OTHER WELL PITS/SUMPS- O <br /> INTENDED USE TYPE,OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ; <br /> C1 Industrial C] Open Bottom' © Manteca r Dia. of Well Excavation Die. of Wall Casing 6] <br /> n Domestic/Private ❑ Gravel Pack t C] Tracy Type of Casing Specifications <br /> t <br /> I"1 Public {1 Other fl Delta Depth of Grout Seal Type of Grout <br /> I I irrigation —..Approx. Depth t I Eastern Surface Seai.Inslalled by <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction - 13 W611 iliametef <br /> Sealing Material & Depth <br /> Depth . Filler Material & Depth <br /> CP <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION$( DESTRUCTION i I lNo septic system permitted if public sewer is <br /> ~" available within 200 feet./ <br /> Installation will serve: Residence ZCommercial_ Other— <br /> Number <br /> ther Number of living units: /__ Number of bedrooms _ c <br /> Character of soil to a depth of 3 feet: . ' Water table depth <br /> SEPTIC TANK EIType/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. Ll Method of Disposal <br /> Distance to nearest: Well Foundation Property.Line <br /> LEACHING LINE CI No. & Length of lines - 'T otakle_ngth/size f <br /> FILTER BED ❑ Distance to nearest: Well Foundation _ - Property Line <br /> SEEPAGE PITS 11 Depth Size Number' <br /> oundation" Property Line <br /> SUMPSell F <br /> ClL1 Distance to nearest: .., � <br /> DISPOSAL PONDS ❑ Y <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 /> ! <br /> Homs 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 perfnrrrlance.of the,work for which this permit is issued, I shall employ persons subject to worbman's compensa <br /> tion laws of California." ? f # • <br /> k The applicant must call for II re fired inspections. Complete drawing on reverse side. t <br /> f Signed X Title: Data: <br /> � X/ t OR ART NT USE ONLY <br /> T• <br /> ► 1 Are <br /> Application Accepted by Date <br /> 1 '20 <br /> Pit or Grout Inspection by Date Finei Inspection by •Date <br /> 0_7 <br /> Additional Comments: <br />' Applicant k Return all copies to: Sen Joaquin County Public Health , 0 <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEEAMOUNT'DUEAMDUtVT.REM1T7.5D� C/KS -"_.XRECEIVED-BYt —.DATE PERMIT_NO. <br /> INFO <br /> a EH 13-241REV.1/85) <br /> EH 14.25 <br />