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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY -PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> © G 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PEWIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made.to San Joaquin County for a permit to construct and/or inetall 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 /> rr <br /> Job Address Ci ze/Acreage <br /> Owner's Name ' Address Phone <br /> Conlractor Address-afSD icense No. Phone_ <br /> k TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS R— <br /> INTENDED USE TYPE OF 1NELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> E7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I') Public 1-1 Other 11 Delta Depth of Grout Seal Type of Grout <br /> 11 Irii ation APProxDepth <br /> I I Eastern Surface Seai installed nd <br /> r by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material &Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION TRUCTION 7. available <br /> o septic system permitted it public sewer.is <br /> within 200 feet.) <br /> Installation will serve: Re idents Commercial ther <br /> Number of living units: Number of bedroo <br /> Character of soil to a depth of 3 feet:41----7 g Water table depth <br /> SEPTIC TANK a/Mfg! apacity Na. Compartments <br /> PKG. TREATMENT PLT. ❑ J / Method of DI§ <br /> o�ah <br /> Distance to nearest: Well Foundation _ Property Line _ <br /> LEACHING LINE No. & Lengthof_lines Tfa Total length/size <br /> FILTER BED Cl Distance to nearest: Well ¢ _ � P y <br /> Foundation � 'f Pro ert Eine er <br /> SEEPAGE PITS 11 Depth Size Number _ <br /> SUMPS U1 Distance'to nearest: Well t Foundation s Property Line y <br /> DISPOSAL PONDS ❑ .1 y { <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 JoaquinCounty j <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 tolbecome subject to workman's compensation laws of-Califbrnia."'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'app I m c E fo all�reedi! ctio mp drawing an r de. <br /> Signe Tl le: Date: <br /> DEPARTMENT USE ONLYApplication Accepted by Z���FOR <br /> Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: ( j <br /> r <br /> ..T.. ,^,,,,_�.t....ter----,-.•..-.-•.,--'"..._ ��-.-'-•.....,., •.-.-„--.,��--"�---�..-��-..»�...-._ -"• <br /> Applicant - Return all copies to: rSeua Joaquin'County Public Health <br /> f Services, Environmental Health Permit/Services <br /> l 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE <br /> t. <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY OATE PERMIT'NO. <br /> • .r i <br /> + EHt4.MIREV.irnsi �I iO0 rCfQ �87 <br /> Jj ' <br />