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APPLICATION FOR PERMIT / <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION C <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> EXPIRES 1 YEAR FR M ATE 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�Pu`blic Health Services.. ` <br /> Job Address __.�!..,�� _ /G rl� i � — City Lot Size/Acreage <br /> RSJwner*s Name �L�/.■[/1.a_[-,/� ddress Phone <br /> Contractor J/t��� Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 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 /> AGRICULTURE WELL OTHER WELL PITS/SUMPS T <br /> INTENDED USE TYPE OF WELL PROBLEM ARE UCTION SPECIE <br /> Cl Industrial El Open Bottom ❑ Manteca Dia. xca Dia. ofe r <br /> C7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I') Public Cl Other to Depth of Grout Seal a of Grout <br /> I i Irrigation _.A epth I I Eastern Surface Seat Installed by <br /> Repair Work Done ype of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION (Na 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. O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well foundation Property Line tv <br /> LEACHING LINE ❑ No. a& Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL 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 taws 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 /> tion laws of California." <br /> The applicant must call for all required ' pectin Co Iota drawing on reverse side. <br /> Signed Title: Date: <br /> F TMENT USE ONLY c <br /> Application Accepted by Data '(� Area /) <br /> Pit or Grout Inspection by Date Final Inspection by Date6 �U <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services `n <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201FEE ` <br /> INFO A OUNT DUE AMOUNT REMITTED C RECEIVED BY //DATE PERMI1'NO. <br /> J <br />