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APPLICATION .OR PERMIT <br /> r-N <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 <br /> <? - P 0 BOX 2009, STOCKTON, CA 95201 <br /> PMIT EXP RPS 1 YEAR FR MDA E ISSUED <br /> j (Complete in Triplicate) <br /> Application is hereby made,to Sari 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 662 and the Rules and Regulations of San <br /> Joaquin County Public Health Be ices. %� <br /> Job Address L City Lot Size/Acreage <br /> i <br /> Owner's Name Address Phone <br /> Contractor AddressC License fQo Phone <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑- DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR1\ OTHER ❑ Monitoring well U <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 /> C] Industrial C] Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> - 7kMomestic/Private ❑ Gravel Pack} ❑ Tracy Type of Casing t Specifications <br /> ~ FPublic fa Other IL 1-1 Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation —.Approx. Depth A I EasternSurface Seal Installed by <br /> Repair Work Done j K Type of Pump 0.i'"' — H.P. A& State Work Done <br /> " Wall Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material b Depth :k <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION 1.1 DESTRUCTION I I (No septic system permitted if public sewer is <br /> `> available within 200 feet.) ` <br /> µ <br /> Install <br /> aiion will serve:-Residence..`- Commercial— Other <br /> Number of living units: Number of bedrooms ; <br /> Character of-ail of"3-feef'"* Water table depth <br /> SEPTIC TANK 'y' ❑ Type/Mfg Capacity Na. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> c � Method of Disposal <br /> " : Distance to6nearest: Well Foundation 1 <br /> x.. , Property Line, <br /> LEACHING LINE Cl. fVa. &,Length of lines Total length/size <br /> FILTER BED D Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I DepthSize Number t <br /> SUMPS 1 LI Distance to nearest: Well Foundation Property fine <br /> DISPOSAL PONDS ❑ ,i <br /> I hereby certify that•l have prepared•this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules-a,nd-rdgulations of the San Joaquin County <br /> Home wner or licensed agent,'a 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 pertion in such-manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub contracting sign ure <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' co ensa- <br /> tion iaws-of California':" <br /> The applica ust II for all require spectio omplele drawing on ro rse side. <br /> Signed rI <br /> Title: Date: Z <br /> USE_ ONLY <br /> Application Accepted by <br /> Date Area <br /> Pit or Grout Inspection by Date Final InspectionD <br /> byT p <br /> ate <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 95201FEE I <br /> L11 <br /> AMOUNT DUE I AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> CASH I' <br /> . EH 13-24[REV,i/A 51 � <br /> EH 34.20 <br /> 1 <br />