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APPLICATION FOR PERMIT <br /> 3'%o6 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOR 2009, STOCKTON, CA 95201 <br /> PERMITEXPIRES 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 /> 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. J C� <br /> Job Address City S,I L, Lot Size/Acreage <br /> Owner's Name Address Phone V <br /> ContractorIT( s License NC Phone 16 OL <br /> TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT M DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <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 /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> [:l Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications <br /> {'1 Public is Other n Delta Depth of Grout Seal Type of Grout <br /> 1 1 Irrigation —Approx. Depth I ) Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth + <br /> Depth Piller Material & Depth +--� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION M REPAIR/AODITION I 1 DESTRUCTION I i INo septic system permitted if public sewer is <br /> available within 200 feet.) �-�- <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 isggsal <br /> Distance to nearest: Well Foundations Property Line <br /> LEACHING LINE ❑ No. & Length of limes 12 Total length/size <br /> FILTER BED 0 Distance to nearest: Wel Foundation Property Line -_5 12� <br /> i <br /> SEEPAGE PITS 11 DepthNumber <br /> MP LI Distance to nearest: Well 7 " Foundation Property Line 4422 <br /> ISPOSAL PONDS ❑ <br /> 1 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 workman's compensation laws of California." Contractors hiring or subcontracting 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 /> The applicant must call for requir i pectionsI Comp) drawing on reZarV side. <br /> Signed X Title: — <br /> Date: <br /> Fsi_�Ln . DDEPARTMENT USE ONLY E <br /> Application Accepted by 1 <br /> Date �~ D Area r <br /> i <br /> Pit or Grout Inspection by Dae Final Inspecti b Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health , ` �K1� <br /> Services, Environmental Health Pe t/ServicesFrl g <br /> l' Gj <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 04� SFEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERM17'NO. <br /> + EN <br /> EH1�26tREV.t/K51 70.UD <br />