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APPLICATION FOR PERMIT <br /> .. SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE 009)4 8-3420 <br /> P O BOX 2009, STOCKTON, CA-95201 <br /> DRRYTT EXPIRES 1 YEAR FROM DATE IPSUED <br /> - . . -((3omplete in Triplicate) <br /> Application is hereby rade to San Joaquin County for a permit to construct and/or install the worlt berein described. his <br /> a aa .T <br /> ication is made in compliance with S -oe3gain County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> City Lot Size/Acreage Ar <br /> Job Address <br /> -� �- <br /> U <br /> Owner's Name Address <br /> �e� �' <br /> _ I�- 4 - Phone <br /> Contrattor Address License No. hone_ <br /> TYPE OF WELL/PUMP: NEW WELL LJWELL REPLACEMENT n DESTRUCTIMIaout of Service Well C <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR D <br /> OTHER ❑ Monitoring Well <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 /> Dia. of Well Casin <br /> C7 Industrial ❑ Open Bottom 0Manteca Dia. of Well Excavation g �. <br /> F7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'I Public C) Other n Delta Depth of Grout Seal Type of Grout <br /> I I lrri0ation —.Approx. Depth t I Eastern Surface Seal Installed by _ <br /> Repair Work Done 0 Type 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 l I REPAIR/ADDITION I I DESTRUCTI 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. O Type/Mfg Capacity -- No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property line F <br /> SEEPAGE PITS 1 1 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> I 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 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 /> Theapplicant ust call for all re wired inspections. Complete drawing on reverse side. <br /> Signed oz Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> i Application Accepted bye~ Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date A19 <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUEMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> INFO GASH �x( <br /> EN 13.24 IREV.t H si ` U D`— <br /> EH A-2e <br />