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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 <br /> PERMIT EXPIRES 1 YEAR FROM DA19 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 trade 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 AddressAi <br /> City Lot Size/Acreage <br /> Owner's Name Address Phone <br /> Contractor Address ,cense No. a Phone <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> F� industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 'Ola.-of-Well Casing " <br /> [:I Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing ' Specifications-' <br /> Il Public is Other Cl Delta Depth of Grout Seal ) Type%of Grout 1`r <br /> I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by t - <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> t y ` <br /> Well Destruction © Well Diameter Sealing Material & Depth r ', <br /> Depth Filler Material & Depth <br /> I <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION LjIRIADDITION I I DESTRUCTION # I (No septic system permitted if public sewer is <br /> � � available within 200 feet.) <br /> Installation wild serve: Re idents!—Commercial_ Other <br /> Number ot.living units: .? Number of bef <br /> Character of soil to a depth of 3 feet: o s - , Water table depth <br /> SEPTIC TANK e fg J- Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ r•'. Methodof Disposal <br /> +t-- � . <br /> Distance to nearest: Well Foundation Property party i.ine <br /> LEACHING LINE of lines �.(7' _ _ Tota length/size <br /> FILTER BED 0 -Distance to nearest: WeII� � Foundation Property Line <br /> SEEPAGE PITS t�h ��_ .sire Nurn for r <br /> SUMPS CI Distance to nearest: Well Foundation'- _,J.YfQ/ Property Line <br /> DISPOSAL PONDS C]f P hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, andrules and regulations of the San Joaquin County 1 I . <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 /> ce�fla�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 /> tiok Laws oFC iiforni ; 4 <br /> The applicantMu ;Ctll #or al) req i ed in C mplgte di wing on re r sider <br /> Signe tTitle; �� date: ` <br /> t F RIDEPARTMENT USE ONLY <br /> T C..�� I 7 <br /> A cation Accepted by Date 1 1 1 Area <br /> Pito rout Inspection by Date S=� Final Inspection by�✓ �--_ DateIr <br /> k <br /> II Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health �pjl <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEECK <br /> INFO AMOUNT DUE AMOUNT(REMITTED CASH RECEIVED BY DATE PIER�rMI.�T�tyNO. <br /> • EH 13-211REV.tix5r ON- {^/ <br /> 7 <br /> EH 14-26 'l RRR��� <br /> i <br />