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` APPLICATION FOR PERMIT <br /> I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> # ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 <br /> ( P 0 BOX 2009, STOCKTON, CA 95201 <br /> EXPIRES 1 MAR FR M DATE ISSUED <br /> (Complete in Triplicate) r <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 - - _ '�- City Lot Size/Acreage <br /> Owner's Name Address Phone o �� <br /> Contractor ddress ( <br /> icense No. � Phone / 7" <br /> TYPE OF WELL/PUIVIIPNEW 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 /> n Industrial ❑ Open Bottom D Manteca Dia. of Well Excavation Dia. of Wel! Casing <br /> C:7 <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy. Type of Casing Specifications. <br /> I') Public C) Other Delta DepGrout Seal Type of Grout <br /> I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material 8 Depth I <br /> Depth t ► Filler Material 3 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIRIADDITION I I DESTRUCTION i I (No septic system permitted if public sower is <br /> ' f <br /> Installation willserve: !Reside 1. <br /> !? # Commercial____ Other available within 200 feet.l _ <br /> Number of living units:? Number of bedrooms <br /> Character of soil to a depth of 3 feet:. . Water table depth !r <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments 1 <br /> PKG. TREATMENT PLT, ❑ Methodof sal <br /> Distance to nearest: Well Foundac n...y a Property Line�_ <br /> LEACHING LINE ❑ No. & Leng;h of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Welt { _ Foundation _ Property Line- <br /> SEEPAGE PITS 11 depth Siia ° <br /> 4 Number <br /> SUMPS 11 Distance to nearest: Well Foundation��_ Property Line_ �_ <br /> DISPOSAL PONDS <br /> ! 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: "t 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 of sub-contracting signature <br /> 'certifies the following: "!certify that in the performance of the work for which this permit is issued, I shall employ ` <br /> tion taws of California." p Y persona subject to workman's campensa <br /> The applicant must call f 1! re u'ed spections, om 40 drawing on reverse side. <br /> Signed X Title: <br /> Date: <br /> FOR DEPARTMENT USE ONLY ! o <br /> Application Accepted by Data /,7'Z 7 <br /> Area <br /> /orGrout Inspection by Date — Final Inspection by _4 <br /> Date <br /> Additions! Comments: i <br /> Applicant - Return an copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> i601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO ASH RECEIVED BY DATE PERMIT'NO. <br /> . EM i14-26 <br /> 3-2t(REV.F/9 Si 1 1 (no 0 ' lV 90' 7 <br /> EH 13-24 <br />