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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)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> �EnuTm FXDTRRS 1 YEAR FROM DATE ISSUE <br /> Re_9u �5 � (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County ror a permit to construct and/or instAtt 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 /> City ���^ Lot Size/Acreage <br /> Job Address <br /> �J Phone — <br /> Owner'e Name 0 Address <br /> G ALicense No. Phone <br /> Contractor ddress r - <br /> TYPE OF WELL/PUMP , 1 INEW WELL ❑.i _ WELL REPLACEMENT C_ DESTRUCTION Ll Out of service Well Monitoring Well LI <br /> PUMP INSTALLATION.❑ =,_= <br /> s_ •r_SYSTEM REPAIR �" - OTHER' O <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> F Industrial C] Open Bottom ❑ Manteca Dia of Well Excavation Specifications <br /> fl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing- <br /> F I Public <br /> ;.l Other I Delta Z Depth of Grout Seal Type of Grout <br /> �Irri anon —Approx. Depth I Eastern Surface Seal {nstalfed by <br /> H.P. State Work Done c <br /> U' > <br /> Repair Work Dorie, Type of Pump -Sealing Material i Depth <br /> Well Destruction O Well Diameter .. <br /> 1 % Depth Filler Material i Depth l� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted it public sower is C} <br /> available within 210 feet.) <br /> Installation will serve: Residence_' Commercial Other <br /> Number of living units: Number of bedrooms - <br /> Character ot1Water table depth <br /> soil to s depth of 3 feet: <br /> SEPTIC TANK 1 ❑ Type!Mtg r Capacity No. Compartments <br /> Method <br /> PKG. TREATMENT'PLT. ❑ ne <br /> Lof Disposal <br /> Line <br /> Distance to nearest:�Well Foundation Property L <br /> LEACHING LINE LI No. b Length of lines Total length/size <br /> FILTER BED Cl Distance to nearest: F Well Foundation Property Line <br /> i„ <br /> SEEPAGE PITS 11 Depth --Size Number J , <br /> PPI a Line <br /> SUMPS <br /> LI Distance to nearest: Well Foundation's `P ny <br /> DISPOSAL PONDS r.1 _ , <br /> I <br /> I hereby certify that t have prepared this application and that the work will be done in accordance with San Joaquin cou Jty ordinances, state laws. an <br /> rubs and regulations of the Sen Joaquin County I M ` <br /> Home owner or licensed agent's signature certifies ttie n the performance of the work for w <br /> following: "l r:erdy that in 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 subcontracting signature <br /> certifies the following: "I certify that in the performance of the woik for which this permit is issued,i shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> Thee mus call for a4required1rCjtjo/.. Complo drawing on,i v isoSignedrry� 4 - Date:v " FOR DEPARTMENT USE ONLY <br /> n <br /> P t % Date - v Area <br /> Application Accepted by <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Additional Comments: K <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> ` Services, FStvironmental Health Permit/Services t i. , 1 1 ►�`, ' <br /> 1601 E. Hazelton Ave.. P 0 Box 2009, Stockton, CA 95201 LhJ <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE'j PERMIT NO. <br /> j INFO (� CASH 1 <br /> I EH 13-24 IREV.I/M 51 �•OO O Yt 17! <br /> I EH 14.25 <br />