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APPLICATION FOR PERMIT <br /> P' s <br /> ` SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES NDU FM Qt�u+� . <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZEL ON AVSTOCKTONE CA95201 �o 6 �M <br /> P O BOR n (� <br /> RES 1 YEAR FROM DATE <br /> (Complete in Triplicate) <br /> Application Is hereby made to Sen Joaquin County for a permit to construct and/or install the work herein described. This <br /> with San Joaquin County ordinance No. 549 and 1$62 and the Rules <br /> application is made in compliance and Regulations of San <br /> Joaquin County Public Health Services. <br /> �'� Q� t � City ��.C�'-ry Lot Size/Acreage <br /> Job Address <br /> MM Address Phone <br /> hOwner's Name <br /> \\\\ Address License No.�Phone <br /> Contfaclor ,DESTRUCTION ❑ Out of Service We11 0 <br /> YPE OF WELLIPUMP! NEW WELL WELL REPLACEMENT,[}_ t. _ Monitoring Well Ll <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> SEWER LINES J..�-- DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> {� Industrial ` Specifications <br /> f ['.I Domestic!Private ❑ Gravel Pack 0 Tracy Type of Casing <br /> ICl Delta Depth of Grout Seal Type of Grout <br /> I'1 Public I:� Other <br /> I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by <br /> of Pump H.P. State Work Done <br /> Repair Work Done 0 Type Sealing Material & Depth <br /> Well Destruction ❑ . Well Diameter <br /> Depth <br /> Filler Material & Depth r <br /> ' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION vailseptiable 7bl, <br /> ithin0 ern rmiitted if public sewer is'' <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms Wadepth <br /> Character of soil to a depth of 3 feet: <br /> Capacity Nortments <br /> SEPTIC TANK ❑ Type/Mfg MeDisposal ""PKG. TREATMENT PLT. ❑ rDistance to nearest: Well ` Foundation Property <br /> \� Vr Total length/size <br /> yam\ LEACHING LINE L) No. & Length of lines <br /> \ FILTER BED (1 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth 'Size Number <br /> SUMPS Ll 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 i <br /> Home owner o►licensed agent's signature certifies the' "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 of sub-ccntracting signature <br /> cartifies the following: "I certify that in the performance of the work for which this permit is issued, t shall employ persons subject to workman's compensa- <br /> tion Yaws of California." <br /> The applicant ust call for all ns <br /> required 'nspect. . Complete drawing on reverse side. <br /> Signed XIT <br /> Title: Date: 7 — <br /> F pq E ONLY 4 <br /> Date Area <br /> Application Accepted by <br /> Pit or Grout Inspection by <br /> Date Final Inspection by <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 /> E,��ECK RECEIVED BY DATE aPERMIT'NO. <br /> EH13-24[REV.I/AW <br /> AMOUNT DUE AMOUNT REMITTED CAS� <br /> r <br /> r <br /> EH 14.25 <br />