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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> I� ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> it I EXPIRES 1 YEAR FROM DATE ISSUED <br /> ki (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 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> j City Lot Size/Acreage <br /> I Job Address 1 <br /> ress <br /> '7' <br /> Owner's Name Phone <br /> - - s <br /> .� Icense No Phone <br /> Contractor <br /> TYPE OF WELL/PUMP. NEW WELL ElWELL REPLACEMENT IJ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR ❑ OTHER E) Monitoring Well [3 <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 /> Cl Industrial ❑ Open Bottom E) Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic I Private ❑ Gravel Pack ❑ Tracy 'Type of Casing Specifications <br /> I'l Public FI Other I (l Delta Depth of Grout Seal Type of Grout (�\ <br /> I i Irrigation — Approxi Depth I I Eastern Surface SIeal Installed by v\ <br /> Repaif Work Done 0 Type of Pump H.P. State Work Done_ <br /> Wei estruction El Well Diameter Sealing Material & Depth <br /> Depth * -Filler Material'& Depth <br /> i TYPE OF SE WORK: NEW INSTALLATION I. I REPAIR/ADDITION 1 1 DESTRUCTIO l No septic system permitted ublic sewer is <br /> j I ` av=table <br /> + t ! <br /> €k Installation will serve: esidence— 'Commercial_ Other ' <br /> Number of living units: Number of ON <br /> Character of soil to a depth of 3 <br /> SEPTIC TANK ❑ Type/Mfg I Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest:Y Well Fou ron Property Line <br /> LEACHING LINE Ll No: & Length of lines Total length/size <br /> FILTER BED (_l'-Distance to nearest: I• Foundation Property Line <br /> I i <br /> SEEPAGE PITS 11 ;Depth Size ti Number <br /> SUMPS f lDistan o nearest: WeN~ Foundation Property Line <br /> DISPOSAL PONDS ❑ f <br /> I hereby certify that I e prepared this application and that the work will be done in accordance w1 an Joaquin county ordinances, state laws, and <br /> rules and regul s 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 finusli tali for all req ' spections. Compl drawing on reverse side. <br /> Signed Title: Date: <br /> ��Fll,\,DEPARTMEI%17T USE ONL <br /> i <br /> Application Accepted by ZA ADate Area <br /> Pit or Grout inspection by Date Final Inspection by Data <br /> Additional Comments: Tx Ec/ �f <br /> Applicant – Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/services <br /> 1601 B. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> CK N <br /> r I <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT•NO. <br /> k / <br /> a EH 13-24 IREV.t/n 51 —� /` ICl LQ <br /> EH 84.28 <br /> I <br />