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� T <br /> ,a <br /> 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 O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE 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 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address _ City ' / 6t Size/Acreage j <br /> Owner's Nam e'�� [�l % //Z- Address ;�� r ' A*,te A Phone J <br /> Ci <br /> r^ <br /> Contractor L/— Address- .+a- �i License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO N AREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> N AGRICULTURE WELL OTHER WELL UMPS <br /> INTENDED USE TYPE OF WELL P A CONSTRUCTIONSPeCWVCATIONS <br /> L1 Industrial ❑ Open Bottom ❑ Manteca Dia. cavation Dia. of Well Casing <br /> f7 Domestic lPrivate ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'1 Public C1 Other a Depth of Grout Seal Type of Grout <br /> I I Irrigation .Appralr, t I Eastern Surface Seal Installed by <br /> Repair Work Done L7 Type ql ump H.P, State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material b Depth <br /> I <br /> Depth Filler Material b Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I I DESTRUCTION I No 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. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal r <br /> Distance to nearest: Well Foundation Property Line n <br /> LEACHING LINE ❑ No. & Length of lines Total length/size j <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire Number <br /> I <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> I <br /> DISPOSAL PONDS 0 ; <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 i <br /> Home owner or licensed agent's signature certifies the following: "t 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 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 a for all require coons. Complete drawing on r verse side. <br /> Signed —. Title: pate: <br /> d <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by ___.. _ Date Area <br /> Pit or Grout Inspection by Date Final Inspection by ate f <br /> Additional Comments: a # CJ -0 `�� <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E.' Hat:elton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> a EH 13-21(REV.1 h 5) � 0- r �/ I LL, I f' 1�kj. tbs <br /> EH 11.26 fff 1 <br /> I <br />