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APPLICATION FOR PERMIT j <br /> ` SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> i <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468--3420 <br /> P 0 BOR 2009, STOCKTON, CA 95201 <br /> I� EXP RES 1 YEAR FRQM DATE E <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 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health 3ervice�. <br /> City alw-- Lot Size/Acreage <br /> € Job Address <br /> fff /� � ddress Phone <br /> Owner's Name � - , <br /> Contiaclor dress <br /> License NO.' Phone <br /> I WELL REPLACEMENT C7 DESTRUCTION ❑ Out of Service We11 ❑ <br /> TYPE OF WELLIPUMP: NEW WELL ❑ - OTHER ❑ Monitoring Well <br /> ' PUMP INSTALLATION ❑ SYSTEM REPAIR10- <br /> DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PITSISUMPS <br /> FOUNDATION AGRICULTURE WELL. OTHER WELL <br /> ± INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> L"1 Industrial [DOpen Bottom 0 Manteca Dia" of Well Excavation + <br /> Type of Casing Specifications <br /> to <br /> Domestic/Private ❑ Gravel Pack E3 Tracy Type of Grout <br /> I'1 Public Cl Other n Delta Depth of Grout Seal <br /> I } Irrigation _ _.Approx. Depth I I Eastern Surface Seal Installed by <br /> k H P State Work Done <br /> F Repair Work Done ® Type of Pump Sealing Material & Depth <br /> Weil Destruction ❑ Well Diameter Filler Material & Depth T <br /> f Depth <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION PAIR/ADDITION I I DESTRUCTION I I (No sbptiw thin 200 lestperm�t�ed if public sewer is <br /> i .system <br /> Installation will serve: Residence_L_,_-Commercial_ Other <br /> Number of living units: �_ Number of beprooms <br /> } Character of soil to a depth of 3 feet: [- f` Water table depth <br /> i SEPTIC TANK ❑ Type/Mfg Capacity _4 . No, Compartments <br /> PKG. TREATMENT PLT. ❑ Method ofPisposal <br /> Distance to nearest: Well _?�P—`, Foundation Property Line <br /> LEACHING LINE & Length of lines '� Total length/size <br /> i FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> s Nu- er. <br /> SEEPAGE PITS LL--Depth Size 9r��I��� 'j�� <br /> I SUMPS LI Distance to nearest: Well.�[6! Foundation� Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 /> I 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 ws aiifornia." <br /> The applicant r u all or all qui d ins tion a wing on verse side r- <br /> Signed itle: Date: <br /> D NT USE ONLY <br /> Date Area <br /> Application Accepted by <br /> Pit or Grout Inspection by w Date Final inspection by_ _Date. �- <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 MOUNT DUE -AMOUNT REMITTED CASH RECEIVED BY DAT£ PERMIT]NO. <br /> O <br /> S 5-11�a C/o <br /> . EH 33.24 IREV.r x S! <br /> EH 14.26 <br />