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APPLICATION FOR PERMIT <br /> S) <br /> SAN <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION No <br /> 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PFRMIT EXPIRES 1 YEAR FROM DATE ISSUED t ' <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 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. t <br /> Job Address City L5J Lot Size/Acreage <br /> Owner's Name Address ���, Phone <br /> Contractor License N CW/r Phone <br /> TYPE OF WELL/PUMP; NEW WELL-❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. .-"LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WEL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SP ATIONS <br /> E Industrial ❑ Open Bottom ❑ Manteca Dia. of cavation Dia. of Well Casing j <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy a of Casing Specifications <br />_ I'I Public LI Other +- �"" 'f' D "-^"'Depth-bf Grout-Saal----�—. Type of Grout j <br /> I I Irrigation A <br /> g' _. pprox, Depth # Eastern Surface Seal Installed by <br /> Repair Work Dane 0 Type of Pump{ H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter z— " 'Sealing-Material & Depth C <br /> Depth t Filler Material ✓E Depth <br /> I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION i I DESTRUCTION t o septic system permitted if public sewer is <br /> i `. € available within 200 feet.) <br /> Installation will serve: Residence_. Commercial Other r <br /> Number of living units: Number of bedrooms <br /> r <br /> Character of soil to a depth of 3 feet: I Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity . No. Compartments ; <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ Na. & Length of line—s '—­­ � � ���� Total length/size <br /> FILTER BED 0 Distance to'nearest: Welt Foundation, Property Line <br /> SEEPAGE PITS 11 Depth sirer f f" t 'Number �f <br /> SUMPS LI Distance tolnearest: 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 i <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 taws of California." Contractor's hiring or sub-contracting signature 1 <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." t <br /> The applicant sl call for all required in fpecti ns. Complete drawing on reverse side. <br /> Signed # Title: La - - Date: <br /> FO EPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit Or Grout Inspection by Date Final Inspection y at (J <br /> Additional Comments.- <br /> Applicant <br /> omments: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 /> IFEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY '^ DATE PERMIT NO. <br /> r EH 14: IAEV .I/ n 51 <br /> ,•�� J 1 [�i� ��� l(a I ' <br /> I <br />