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APPLICATION FOR PERMIT <br /> SAN J'OAQUIN 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 <br /> IT EXPIRES 1 YEAR FROM DATE ISSUED_ <br /> (Complete in Triplicate) <br /> I <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 1$62 and the Rules and Regulations of San <br /> Joaquin County Public th Services. <br /> f <br /> Job AddressKCity of Size/Acreage <br /> Owner's Name dress } Phone <br /> Contractor <br /> ° aress License No.� Phone <br /> TYPE OF WELL/PUMP.. NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION o Out of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <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 /> n Industrial ❑ Open Bottom ❑ Manteca €Dia. of Well Excavation Dia. of Well Casing I <br /> [I Domestic/Private 0 Grave! Pack; ❑ Tracy Type of Casing Specifications <br /> I'1 Public Cl Other Cl Delta Depth of Grout Seal Type of Grout <br /> I } Irrigation —,.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0%. Type of Pump-r H.P. ` State Work Done " <br /> Well Destruction O Well Diameter`l Sealing Material & D <br /> Depth F Filler Material pth <br /> TYPE OF SEPTIC WORK: -NEW INSTALLATION I I REPAIR/ADDITION l DESTRUCTION I I INo septic system permitted if public sewer is <br /> t available within 200 feet.I <br /> Installation will serve: 'Residence Commercial Other." w r <br /> Number of living units' h Number of bedrooms-L <br /> — <br /> Character of soil to a depth of 3 feet: ; Water table depth <br /> SEPTIC TANK 0 Type/Mfg!l Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ }; Method of Disposal <br /> Distance to.nearest: Well Foundation Property Line <br /> t <br /> LEACHING LINE 0 No. & Length of lines Total length/size In <br /> ILTER BED n Distance toynearest: Well f Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sue Number <br /> SUMPS LI Distance to nearest: Well Foundation . Property Line <br /> DISPOSAL PONDS ❑ tI r <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 signaturg'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 inIsuch 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 /> The applicant mu t can all r wired in ctio s. Co <br /> mplete ra g o ' ver a side. <br /> Signed X itle: ` Date: <br /> if <br /> FO T USE ONLY_--.,, <br /> I <br /> �7 I <br /> Application Accepted by L Date_l Area J <br /> Pit or Grout Inspection by t Date Final Inspection by Date) d <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 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"N0. <br /> INFO / CASH <br /> a EN iC24tREV.tinsl <br /> Zb <br /> EN 29 0c) I r 7D 7197 90 <br /> ff G <br /> i <br />