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Ar <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> A. 1601 E. HAZELTON AVE. , PHONE (209)468-3420 � tt. <br /> P O BOR 2009, STOCKTON, CA 95201 <br /> ' EXPIRES 1 YEAR FR M E <br /> (Complete in Triplicate) <br /> Application Is hereby made to Sani.Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance iwith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> ! Lot Size/Acreage .Y <br /> Job Address i City <br /> 1� <br /> OAddress <br /> Phone <br /> Owner's Name <br /> ` Address License Na ��7y Phone <br /> Contracts <br /> TYPE OF W L/PUMP. . NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well C1 <br /> Monitoring Well <br /> PUMP INSTALLATION C7 <br /> SYSTEM REPAIR El OTHER ❑ ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> CIndustrial U Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> -1 <br /> C..l Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> # I'I Public 1-1 Other F1 Delta Depth of Grout Seal Type of Grout <br /> I I IrfiUation —.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth ' Filler Material 5 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR IADDITION I I OESTRUCTIONY aMo <br /> withinsystem reined if public sewer is <br /> eet <br /> Installation will serve: Residence�A Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet:'I Water table depth <br /> Capacity — Na. Compartments <br /> SEPTIC TANK, ❑ -Type/Mfg <br /> PKG. TREATMENT PLT.0J Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> ' Total len th/size <br /> LEACHING LINE Cl Na. & Length of fines g <br /> FILTER BED 0 Distance to`nearest: Well Foundation Property Line 7 <br /> A <br /> SI EPAGE PITS I i Depth Size _ Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line �] <br /> DISPOSAL PONDS 0 <br />! I hereby certify that 1 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 /> that in the perfor <br /> Home owner or licensed agent's signature certifies the following: "I certify mance rthe work for which this permit issued, I shall not <br /> employ any person in such manner as to become s1bject to workman's compensation laws of California." Contractor's hiring or sub contracting signature <br /> certifies the following: "I certify that in the performs of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of Califor <br /> The applicant ust cif I it d in pe.ctions. Complete drawing on reverse side. <br /> Signed X Title: Date: <br /> r----- FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area r [� q <br /> Date Final Inspection by Data <br /> Pit or Grout Inspection by <br /> l <br /> Additional Comments: <br /> Applicant Return all copies to: San Joaquin County Public Health <br /> !I Services, Environmental Health Permit/Services <br /> 1 <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO w0 � <br /> � <br /> a EH,13-2111tev.r/ sl " '^' `�� • <br /> EH 41.20 <br /> i <br />