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APPLICATIWN FOA PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E_ HAZELTON AVE. , PHONE (209)468--3420 <br /> I P O BOX 2009, STOCKTON, CA 95201 <br /> i <br /> PEMIT EXP RES 1 YEAR FROM DA <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 i <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 <br /> r <br /> Job Address City Y Lot Size/Acreage <br /> Owner's Name Address - Phone <br /> Contractor _.0 AddressA_ License IVo. Phone <br /> TYPE OF WELL/PUMP:,.- NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 <br /> c <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR" OTHER D Monitoring Well C3 <br /> � <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, ,, -,j >r ,.\ <br /> f 1 m <br /> Industrial ❑-Open Bottom ©_Mante_ca. .—Dia. of Well Excavation 'Dia.",of Well Casing <br /> 00 miestie/privaut - I LI Gravel Pack ❑ Tracy- Type of Casing Specifications <br /> / <br /> �-.� Type of Grout <br /> "1 Public f CI%Other Delta�� Depth of Grout Seal <br /> I I Irrigation `'J •'�.Approx. Depth I I Eastern Surface Saal Installed by <br /> Repair Work Done kV Type of Pump H.P. State Work Don <br /> Well Destruction ❑r Well Diametef Sealing Material A Depth <br /> � Depth ' Filler Material b Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is <br /> J^ available within 200 feet) <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms , r r <br /> Character of soil to a depth of 3 feet n t s Water table depth <br /> SEPTIC TANK. D, Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 i i Method of Disposal <br /> Distance to nearest: Well I ' Foundation Property Line <br /> •t .. <br /> LEACHING LINE Cl No. & Length of lines = -Total length/size. } '- <br /> t � v <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> 4 r \ <br /> SEEPAGE PITS I I Depth .f Site Number _..•_, <br /> SUMPS l.:! Distance to nearest: Well ` Foundation . - Property Line f <br /> 111 DISPOSAL PONDS 0 <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 ' 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 /> S certifies the following: "I cenify 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 /> x The ap ant m t call for all fequire inspecli s. Cc to drawing on rave side. <br /> Signed Title: _T, f� _ Date: <br /> FOR DEPARTMENT USE ONLY <br /> 1 �Z C/ s <br /> Application Accepted by Date j' Are <br /> k a <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: �' t -- <br /> Applicant - Return all copies to: San Joaquin County PubliF Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DU8` AMOUNT REMITTED CK RECEIVED BY DATE FE tMIT'NO, <br /> INFO !' L CASH 1 -7 <br /> EH 13.24 MEV.I)As) q'U0 �/4 --5—qv <br /> EH14-25 <br />