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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)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 I' <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUM <br /> (Complete in Triplicate) <br /> Application is hereby made,to San_Joaquin County far 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 /> Job Address 1.2Cit Lot Size/Acreage <br /> Owner's Name jAddress Phone p <br /> Cont=raclor Address CL se No. 43gPhone Z <br /> ' �7YPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well El <br /> OTHER ❑ Monitoring Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ C7 <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 <br /> i 7 Industrial ❑ Open Bottom 0 Manteca` Dia. of Well Excavation Dia. of Well Casing <br /> i l <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> UI public fa Other 1­1 Oeha _ � Depth of Grout Seal <br /> Type of Grout <br /> 11 Irrigation Approx, Depth I i Eastern ' Surface Seal Installed by \ <br /> Repair Work Done C7 Type of Pump H.P. State Work Done — <br /> Well Destruction 1:1Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK:. NEW INSTALLATION hl, REPAIR/ADDITION STRUCTION I 1 [No septic system permitted if public sewer is <br /> available within 200 feet.i <br /> Installation will serve: Re 'deuce l"e6mmerciat Other <br /> Number of living units: Number of bedrooms I <br /> Character of soil to a depth of 3 feet: . � � t _Water table depth <br /> SEPTIC TANK ❑ Type/Mfg '"""" " s "Capacity" No. Compartments <br /> PKG. TREATMENT PLT. ❑ ! Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE `E o & Lengthoflines Total length/size <br /> FILTER BED ❑ Distance to nearest: well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size _ Number <br /> SUMPS Irl Distance to nearest: Well Foundation 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, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the foilowing:,'.'I certify,that_3n the pprformance of the work for which this permit is issued. I shall not <br /> f 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 /> c ifies 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 cornpensa- <br /> ti n Ia of California." <br /> The applica u call f al equ' dins tions _ p drawing an 7seside. <br /> S, Tit Date: <br /> TMENT USE ONLY <br /> Application Accepted by -Date -- -- Are <br /> o Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> fApplicant - Return all copies to, San Joaquin County Public Health <br /> ,- -Services;-Environmental Health­-Permi: /Servi­ees'- <br /> 1601 E. -Haaelton.Ave., P 0 Box 2009, Stockton, CA 95201 <br /> { FEEMOUNT DUE AMOUNT REMITTED <br /> CK RECEIVED BY , DATE PERMIT N0. <br /> INFO <br /> [ . EH 13-24[REV,iinsi <br /> �� v v ?0-13 s'� <br /> EH 11.26 <br /> I <br />