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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT RES 1 YEAR FR9M DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in Compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San �J Joaquin County Public Health Services. Y�Job Address fU�r�/U Cit _ Lot Size/Acreage r �Qwner's Name Ul�ddress l � � �� /_ Phone Contractor Address License No. Phone TYPE OF WELL/P MP: NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION Cl Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS w INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial C1 Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing f 1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i'1 Public fa Other Fl Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction 0 Well Diameter Sealing Material & Depth d Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION l I DESTRUCTION I INo septic system permitted if public sewer is vailable within 200 feet.! Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK: 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line \ � O LEACHING LINE ❑ No, & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 1 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 rules and regulations of the San Joaquin lCounty 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 employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I cartify that in the performance of the work for which this permit is issued, i shall employ persons subject to workman's compensa- tion taws of Cal'ornia." The applicant st call for all required in coons. Complete drawing on reverse ide. C KS_ Title: Date: NLY- Application Accepted by Date Pit or Grout Inspection byv / Date Final Inspection b Date Additional Comments: J� �7 � �fi✓ 1 Applicant - Return all copies to: fSan Joaquin County Public Health ± J Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 Y INFO OUNT DUE f /AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO.