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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1.601 E. HAZELTON AVE. , PHONE (209)46$-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> REMIT EXPIRES I YEAR FROM DATE JUSUED <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 1n compliance with San Joaquin County Ordinance Ho. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address- / S�t� Cit p _ Lot Size/Acreage <br /> ///,t///� S�/ s <br /> Owner's F7ar� �✓L%�Address Phone <br /> Contractor V Address License No. Phone <br /> TYPE Of WELL/PUMP: NEW WELL❑- WEL REP4REPA <br /> DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION ❑ S TOTHER ❑ Monitoring WellDISTANCE TO NEAREST: SEPTIC TANK SEWER LINESISPOSAL FLD. PROP. LINEFOUNDATION AGRICULTURE WTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTR TION SPECIFICATIONS <br /> n industrial © Open Bottom S, �--❑ Manteca Dia. of I Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack I-) TracyType f Ca 'ng Specifications <br /> I"I Public f-1 Other n Delta D th of Gr t Seal Type of Grout <br /> I I Irrigation Approx. Depth l I Eastern urfaee Seal I stalled by I <br /> Repair Work Done 0 Type of Pump H.P. State Work Dona _ <br /> Well Destruction ❑ Well Diameter Seal Material i A h <br /> Depth Fi er Material E Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAI /ADDITION I I DESTRUCTION I (No septic system permitted if public sewer M <br /> available within 200 feet.) ' <br /> Installation will serye: Residence Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: 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 /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation . 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, an <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 /> cartifies 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 /> ThePtion <br /> ust call for requ' ed ' s ctions. C plate drawing side. <br /> IX Si nTitle p e �`fr771� ! Date: <br /> �\ FOR DEPARTMENT USE ONLY <br /> Appepted by Date �� Area CP4 <br /> Pit or Grout Inspection by Date Final Inspection by Date <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 o 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE JAMOUNT REMITTEDASH RECEIVED BY D TE PERMIT'NO. <br /> INFO <br /> . EH 13.24(REV,1/"5) !!/ ♦J�� <br /> CH 14.2e T <br />