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r APPLICATION FOR PERMIT <br /> i <br /> .SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> I P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 /> F 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 /> Job Address ` <br /> • 'City Lot Size/Acreage <br /> Owner's Name Address Phone <br /> Contractor l><..�`f Address License No: r Phone s <br /> Y ' <br /> i <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ <br /> ff PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ � OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST:'SEPTIC TANK -^"--=-SEWER LINES DISPOSAL. FLD. -PROP.'LINE <br /> I FOUNDATION AGRICULTURE WELL r OTHER WELL PITS/SUMPS �t <br /> INTENDED USE, TYPE-OF WELL_PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial © Operi Bottom` ❑ Mantaca Dia. of Well Excavation Dia. of Well Casing <br /> ii Cl Domestic/Private ❑ Gravel-Pack ' y'E7 Tracy Type of Casing Specifications ' <br /> F] Public I:1 Other 1-1 Delta Depth of Grout Seal Type of Grout__ <br /> i I Irrigation t <br /> .Approx. Depth [ I Eastern Surface Seal Installed by <br /> Repair Work Done ; ❑ Type of Pump � H.P. <br /> State Work Done <br /> Well Destruction i ❑ Wel! Diameter Sealing Material & Depth <br /> I Depth Filler Material b Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION EPAIR/ADDITION I I DESTRUCTION I 1 Wo septic system permitted if public sewer is <br /> �.-�.—� , ...k . ,.�— <br /> available within 21x1 feet.) <br /> Installation will serve: Residence r ommercial <br /> Number of living units: ---_F"- NumbAE� <br /> Character of soil to a depth o/3 feet: ^ Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, ❑ E Method of Disposal <br /> Distance to nearest: 11 I <br /> ,Foundatio Property Line <br /> LEACHING LINE U--ITO�g Length of lines_ Topel_iength/sire <br /> FILTER BED is Distance*to nearest: Well Foundation �_ Property Line <br /> SEEPAGE PITS I I Depth Size Nymber <br /> SUMPS M--6t3Tance to nearest: f <br /> DISPOSAL PONDS ❑ V Well Foundation -- Property Line <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 I <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 /> 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 /> te s of California." f <br /> The applican t call or a req ad in ction wing on verse sid . <br /> Sign <br /> Date:_,��- <br /> FOR DEPARTMENT USE ONLY G� <br /> Application Accepted by Date l -.�� 2 <br /> Area <br /> Pit or Grout Inspection by Date Final Inspaction- <br /> --�- <br /> Additional Comments: f?c�ry P- <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 /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED h CK RECEIVED 9Y DATE PERMI7'NO. <br /> f� CASH <br /> ♦ EN 13.28IREV.IJN5) —7 .0l] <br /> EH 14.28j f <br />