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{ <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES Fl�'E ;E I V E D <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 S E P 1 8 1992 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> ENVIRONMENTAL HEALTH <br /> XP RES 1 YEAR FROM DA E ED UMIT/SERVICES <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 ccupliance 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 49' v< City . L 'got Size/Acreage <br /> " Owner's Name /s'"`ddress Phone <br /> Contractor , R 7.� _Address a No <br /> Contractor Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well [7 <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 /> f_-i Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private [!..Gravel Pack ❑ Tracy Type of Casing Specifications <br /> s 1'I Public (] Other n Delta Depth of Grout Seal Type of Grout <br /> I I irrigation —.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work DoneType of Pump H.P. State Work Done <br /> Well Destruction O Well Diameter Sealing Material b Depth <br /> Depth _ Filter Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR IADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.1 <br /> Installation will serve: 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 1-1 Distance to nearest: Well Foundation Property Line <br /> t SEEPAGE PITS i I Depth _ Size Number <br /> SUMPS Ll r 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, 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 workmen's compensation laws of California." Contractor's hiring or 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 C ' nia." <br /> ! The applica t c Ofarequir ins ctio mplete drawing o side. <br /> i <br /> j Signed X r Title; Date: <br /> F EP _USE ONLY <br /> Application Accepted by Date rea <br /> Pit or Grout Inspection by Date Final Inspection b 0 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 0 Box 2009, Stockton, CA 95201 <br /> FEET DUE AMOUNT REMITTED H RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> I a EN 13-24 TREY,i/Is 5;VN <br /> r <br /> EH 14.26 <br />