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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 -E. HAZELTON AVE. , PHONE (209)46$--3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> f PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> r (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. <br /> �l � City Lot Size/Acreage <br /> Job Address <br /> Owner's Name Address Phone <br /> Contractor �«t✓I1 Address 0, License No.692Phone— f <br /> TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL ,,._...--. OTHER WELL PITS/SUMPS <br /> INTENDED USE I TYPE OF WELL PROBLEM AREA. CONSTRUCTION SPECIFICATIONS <br /> n Industrial Cl Open Bottom d Manteca Dia. of Well Excavation Dia. of Well Casing <br /> i •�, ! ❑ Gravel Pack ❑ Tracy ti Type o1 Casing Specifications <br /> [:I Domestic/Private <br /> I'I Public i.1 Other F1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation .. Approx. Depth l 1.Eastern ,� Surface Seal Installed by <br /> AlRepair Work Done 7--p-11-of Pump -- H.P. "' State Work Done _ <br /> F Well Destruction 0 Well Diameter � '�Sealing Material & Depth <br /> 1 Depth :, Filler Material & Depth <br /> k TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION 01 DESTRUCTION I I INo septic system permitted+it public sewer is <br /> 33 ` _ _ _ _,. ,,:,: ,,,� •�,/`�-%-=;�� available within 200 leet.I <br /> Installation will serve:° F16clencez Corimmercial Other <br /> r Number of living units: L_ Number of bedrooms 'r ; <br /> tt Character of soil to a depth,of 3 feet: 'd ba& _._Water table depth r <br /> SEPTIC TANK. 0 !Type/Mfg ,L• � Capacity a No. Compartments <br /> f <br /> PKG. TREATMENT PUT. ❑ �• / j l T! Method of Disposal <br /> hDistance to nearest:. Well; Foundation- A/ Property Line—4-2v_10_� l ' <br /> LEACHING LINE ig ;.No. & Length of lines' — Total length/size D ` <br /> 4 FILTER BED ❑ Distance to nearest: Well/OD'r`' Foundation 6Zy f"2'I Property Line !D <br /> l <br /> SEEPAGE PITS I 1 Depth Size Number — <br /> SUMPS'a. 0 1 Distance to nearest: !Well Foundation . Property Line <br /> DISPOSAL*PONDS , ❑ <br /> ! hereby cenify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> C rules and regulations of the San Joaquin County r r <br /> Home owner or licensed agent's signature certifies the fojlowing: "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 itie 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 all required inspections. Complete drawing on reverse side. <br /> Signed Title; pate: <br /> � IFOR DEPARTNtENT USE ONLY <br /> Application Accepted by <br /> 1 Date 3 Area .//0 <br /> Pit or Grout Inspection by Date Final Inspection by Date 3AS �r <br /> r <br /> Additional Comments: <br /> Applicant — Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> s 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> INFO <br /> EEE AMOUNT OUE' AMOUNT REMITTED CASHK* I RECEIVED BY'- DATE PERMIVNO. <br /> } a EH 13-24(REV.i/'n 5Y oy.� .'� <br /> r EH 14.25 - <br />