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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> I ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1-!EAR FROM DAIR 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 /> f 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 /> t� Joh Address City .._ — Lot Size/Acreage <br /> Owner's Name S• Address n Phone~ <br /> Contractor t� Address �J � <br /> License No. Phone <br /> TYPE OF WELL/PUMP:*^F NEW WELL-0 WELL REPLAC"EMENT-❑ " Y DESTRUCTION-El Crut-of-Service we11 �❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well C� <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 PRO13LEM AREA CONSTRUCTION SPECtFiCATIONS <br /> F) Industria! ❑ Open Bottom �❑ Manteca Dia. of Well Excavation Dia. of Well Casing j <br /> P Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'1 Piiblic Cl Other n Delta f Depth of Grout Seal Type of Grout \ i <br /> I I Irrigation —Approx. Depth I 1 Eastern.. Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work bone _ \� <br /> Well Destruction ❑ Well Diameter Sealing Material A Depth.` \��- <br /> Depth Filler Material & Depth �t <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION N REPAIR/ADDITIOI I DESTRUCTION I I (No septic system permitted if public sewer is <br /> Y ».. - - Y , "available within 200 feet )- <br /> Installation will'serve: Residence `Commercial_ Other <br /> Number of living units: __�— Number of bedro ms <br /> Character of soil to a depth of 3 feet: o e Water table depth <br /> SEPTIC TANK: Type/Mfg �Capacity�` "No. Compartrnerits <br /> PKG. TREATMENT PLT. ❑ / Method of Disposal <br /> Distance to nearest: Well --1 i tet' Foundation .3 _ Property Linef" ` l <br /> LEACHING LINE � ti,, <br /> �No. & Length of lines Total length/size 7 <br /> FILTER BED ❑ Distance to nearest: Well d Foundation 1 <br /> Property Line <br /> SEEPAGE PITS 11 Depth Size ! J{ Number <br /> SUMPS Distance to nearest: Well Foundation property irne;. <br /> DISPOSAL PONDS ❑ r .: <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 d <br /> rules and regulations of the San Joaquin County .„ . 4 <br /> Home owner or licensed agent's signature oenifies the following: "I certify that in the performance of the work for which this permit isssneda 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-coorwRtf's t signature <br /> certifies the following: 1 certify that in the performance of the work for which this permit is issued, I shall employ persona subject to -c6';:ai�'sicompetur <br /> tion laws of California." <br /> The applicant must call for all re fired ' spections. Complete"drawing"an reverse side._Ag <br /> Signed X Title: "^ <br /> Date: . S' <br /> R DEP TMENT 115E <br /> ��� 9,qLY <br /> Application Accepted by <br /> Date <br /> Pit or Grout Inspection by Date Final Inspection b Dat <br /> Additional Comments: <br /> Applicant - Return all 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 AMOUNT DUE AMOUNT REMITTED CK RECEIVED DATE PERMIT'NO. <br /> INFO CASH r A <br /> . EH 13-24{REV.i/n 81 r �^• <br /> EH 74.26 { �� _ri�`} <br /> `�C f l <br />