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µ ; <br /> APPLICATION FOR PERMIT S <br /> SAN JOAQUIN COUNTY 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 /> �. EXPIRES 1 YEAR FROM DATE ED <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 /> liance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> application is made in comp <br /> Joaquin County Public Health services.! CityS" y 4_0r4�-�t <br /> Lot Size/Acreage <br /> l Job Address '1Phone 1/�/.3 O/ �/ <br /> Address <br /> r <br /> ' Owner's Name ` <br /> F l #Phone'_ J <br /> License No, <br /> Contractor <br /> l Address r � ,Q �r � �' _ <br /> l f�)�P' - a Service Well G1 <br /> TYPE OF-WELL/PUMP: NEW WELL,C] .- , ;.WELL REPLACEMENT,C1.,4 DESTRUCTI Monitoring Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISPOSAL FLD. PROP, LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PITS/SUMPS <br /> FOUNDATION "f AGRICULTURE WELL OTHER WELL <br /> k INTENDED USE TYPE OF;WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Casing <br /> ❑ Industrial (5 Open Bottom D Manteca Dia. of Well Excavation <br /> ' Specifications <br /> [I Domestic!Private Cl Gravel Pack n Tracy Type of Casing <br /> Depth of Grout Seal Type of Grout <br /> ±� <br /> I'! Public C1 Other `� f-1 Delta a <br /> I I Irrigation ^.Approx. Depth I I Eastern Surface Seal Installed by <br /> �HP -State.Work-Done <br /> Repair Work Done 0 Type of Pump- __ - H.P;Sealing Material 8 Depth <br /> Well Destruction ❑ Well Diameter Filler Material & Depth (� <br /> Depth <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION { I DESTRUCTION tNo septic system permitted it public sewer is i <br /> ailable within 200 feet-I <br /> Installation will serve: Residence ' Commercial Other <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ f _ Method of Disposal <br /> Distance to nearest: Well foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED {7 Distance to nearest: Well Foundation Property Line <br /> % <br /> SEEPAGE PITS 11 Depth t Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation <br /> Property Line ` <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.,Tan�e <br /> rules and regulations of the San Joaquin County issued, I shall riot <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 1."e- <br /> employ any person in such mariner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> certifies the following: "I certify that iri_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." 11 <br /> The applic n ust calf for all u" +d iygrpjComplete drawing on reverse side. <br /> Signed Title: <br /> _ Date: <br /> 1 <br /> O\DEPARTAAEN7,USE ONLY ^ � , <br /> Application Accepted by <br /> Date Area <br /> O\ <br /> Pit or Grout Inspection by <br /> f Date Final Inspection by ��" '-� — Date <br /> Additional Comments: <br /> r <br /> Applicant Return 9.11 copies to. San Joaquin County Public Health <br /> t Services;iEnvitonmental Health Permit/Services <br /> I 1601 E.`Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DtJE AMOUNT+.REMITTED ASH k RECEIVED BY DATE PERMIT'NO. <br /> t INFO <br /> . EH 1J-21 rrifV.ii++SY ��$-4 <br /> EH:626 _ T' <br />