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APPLICATION FOR PERMIT <br /> SAN JOAQUIN C6UNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PFMIJ EXPIRES 1 YEAR FROM DATE ISSPED <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 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address llea Cit Lot size/Acreagel� <br /> Owner's Name Address ! -�� -] <br /> Phone <br /> Contract r ' r r Address IJ� License No 2 ZZ�Phon - �(1. <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT D 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 /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications <br /> — <br /> ['I Public Cl Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —Approx. Depth I I Eastern Surface Seal installed by i <br /> Repair Work Done 0 Type of Pump H.P. State Work Done _ <br /> Well Destruction 0 Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I i tNo septic system permitted if public sewer is <br /> available within 200 feat.I <br /> Installation will serve: Residence__ Commercial ther <br /> Number of living units: _/_ Number of be ms � <br /> Character of soil to adept of 3 feet: Water table depth <br /> SEPTIC TANK. Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT,PLT. ❑ l r Method of Disposal <br /> Distance to nearest: Well . Foundation la Property Line _1.T _ <br /> LEACHING LINE 2;� No. & Length of lines r � Tota! length/size -,4 <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line _L:�__ — <br /> / /f <br /> SEEPAGE PITS Depth Siref,. umber <br /> SUMPS Ll Distance to nearest: Well Foundation o60Property Line �I <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 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 t call for uir inspections, Complete drawing on reverse s de) <br /> Signed Title: �1 t / _ Date <br /> FOR DEPARTMENT USE ONLY ,a <br /> Application Accepted by Date f Area Z <br /> / P,It or Grout Inspection by Date Final Inspection by 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 /> INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECECK IVED BY DATE PERMIT,NO. <br /> EH 2 24 IREV.I/n sl �,) `� 29 1FLI-l <br />