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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 /> PFAMIT FXPIRES 1 YEAR FROM DATA J,0ffl _TD <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 Services. 1 <br /> r 1 <br /> Job Address City Lot Size/Acreage <br /> I <br /> OwnerSv <br /> 's Name Address <br /> P"�" <br /> IV&At! <br /> Contractor Address License No, Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 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 /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> industrial C1 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Ell Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications <br /> Cl Public 1.3 Other n Delta Depth of Grout Seal Type of Grout <br /> 1 I Iffigation —.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump 9"6 ._. H.P. 1 Y2 State Work Done 't�''r/� Jc <br /> Well Destruction ❑ Well Diameter Sealing gaierial & Depth <br /> ol <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION f I JNo 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 ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. D Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> - l- <br /> LEACHING LINE 0. `No'. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property.Line <br /> SEEPAGE PITS 11 Depth Size Number f <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 <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 /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> 4 <br /> Signed X ride: �� — Date: <br /> FOR DEPARTSE ONLY <br /> .. <br /> of t <br /> Application Accepted by 1 � � Date y Area <br /> iOF <br /> Pit or Grout Inspection by Date Final Inspection by 21ate <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 CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> . EH 13-24IREV.i/H5) �"�D 1� l 00 <br /> + EH a4.2s SST 1 <br />