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{ <br /> f <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1.601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> ZUIJ MIRES 1 YEAR FROM DATE ISj5USD <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 in compliance with San Joaquin County Ordinance No. 549 and 1862nd the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> DCity Lot Size/Acreage <br /> Job Address <br /> r / <br /> Phone <br /> Owner's Name 'f' r <br /> r License Not phone <br /> Contractor Address <br /> TYPE OF WELL/POMP: NEW WELL 71WELL REPLACEMEN W <br /> Monitoring <br /> Cl DESTRUCTION EI of Service Wel <br /> elll <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> --7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> k Ca Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'1 Public Cl Other F Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —Approx. Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done G <br /> Well Destruction ❑ Well Diameter Sealing Material Depth <br /> DepthFiller Material Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR! IDDITION I ) DESTRUCTION I 1 (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> i <br /> Installation wilt serve: Residence...r. Commercial T 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 0 "Type/Mfg /C-,) Capacity No. Compartments <br /> PKG. TREATMENT PLT. C1 Method of Disposal <br /> Distance to nearest: Well /_0 Foundation Property Line <br /> LEACHING LINE 0 LNo. & length of lines y Total length/sire <br /> FILTER BED Cl "Distance to nearest Well C 0 ,fes Foundation _ Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation 7-4 4 Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby c9nAV_Lb4.t_1-Kave 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: "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 /> cenifies the following: "I certify thavin 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." F, <br /> The applicant m t call II wired i ctio s. Complete dra ' g on reverse side:_.=� �^ <br /> Signed itle: /n,---1/7 —--- Date: ?7 <br /> FOR DEP ARTMENT USE ONLY <br /> f �z <br /> Application Accepted by Date Area <br /> ,, l 1 <br /> r t or Grout Inspection by��d2:�Uale 1 --.Final Inspection by Data <br /> I <br /> I <br /> Additional Comments: <br /> Applicant – Return sll copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Servicea <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> t FEE AMOUNT DUE AMOUNT REMITTED CASK RECEIVED BY DATE PERM17'NO. <br /> INF <br /> a EH 13-24 SREV.11 x 51 +�. n '� 1-116-41 -R*- 6 <br /> EH^14,.261 1;! v <br />