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l 1i APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />' ENVIRONUENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> �PEM IT EXPIRES 1 YEAR FROM DATE ISSUED �g <br /> (Complete in Triplicate) / V ? <br /> I <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 end Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address City Lot Size/Acreage <br /> l <br /> Owner's Name„.- Address l a � •/ Phone <br /> Contractor s ddress License No. 0� p0 Phone ,�� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service Well L1 <br /> PUMP INSTALLATION ❑ SYSTEM REP ❑ OTHER ❑ Monitoring well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWE LINES DISPOSAL FLD. PROP. LINE- <br />' FOUNDATION,:. _,,,T AGRI LT WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM_44CA CONSTRUCTION SPECIFICATIONS <br /> 1-1 Industrial © Open Bottom,. ❑ M eca Dia. of Well Excavation pia. of Well Casing <br /> (J Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications <br /> I1 Public Cl Otherfl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation �.Approx. pllh I I EasteIF <br /> Surface Seul Installed by <br /> Repair Work Done ❑ Type of Pump P. State Work Done <br /> Well Destruction C) Well Diameter ealing Material & Depth <br /> Depth iller Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 R AIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available withinfeet,l <br /> Installation will serve: Residence— Commercial_ thea` �� <br /> Number of living units: Number of bedrooms * e <br /> Character of soil to a depth of 3 feel: Water table depth \ <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments �I <br /> PKG. TREATMENT PLT.0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 ' No. & Length of lines A Tota ehigth/size i1l <br /> x` <br /> FILTER BED C7 Distance to nearest: We <br /> SEEPAGE PITS ( I Depth Size Pumber <br /> SUMPS LI ' Distance to nes est: well ndation / Property Line <br /> Jr <br /> DISPOSAL PONDS ElI 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 regutations of the San Jbaqui.n,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 /> ernploy 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; "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 /> I The applicant ust call for iced in ctions..Complete drawing on reverse side. <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Bate Area <br /> _ N �a <br /> Pit or.Grout Inspection by Date Final Inspection by ' Date f� r <br /> I Additional Comments: ! �/ 1 ✓ <br /> Applicant – Return all copies to: San Joaquin County Public Health" <br /> Services, Environmental Health 'Permt/Services may" <br /> 1601 E. Hazelton Ave., P 0 Box 200?, Stockton, CA 95201FEE <br /> U <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK 9 RECEIVED BY DATE. PERMIT'NO. <br /> ♦ EH 14.24(REV.I/w 51 / - <br />