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I APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468--3420 P O BOR 2009, STOCKTON, CA 95201 EXPIRES1 YEAR FROM 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 ectipliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Hea:lth Services. Job Address t -�� K; __— City Lot Size/Acreage Address KO332 6L ,M Phone wner's Name Contractor Address License No. Phone TYPE OF WELL/PUMP: ill; NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ out of Service Nell ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEkIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing El Domestic I Private L3 Gravel Pack ❑ Tracy Type of Casing Specifications f ' I'! Public fa Other nDelta Depth of Grout Seal Type of Grout F I I Irrigation __�Jll_Approx. Depth I I Eastern Surface Seal installed by (Z Repair Work Done ❑ Tyofof Pump H.P. State Work Dane_ Well Destruction ❑ We111 Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION l I DESTRUCTIOtM iNo septic system permitted if public sewer is l available within 200 feet.) i Installation will serve: Residence— Commercial_ Other w Number of living units: 11- Number of bedrooms Character of soil to a depth 11 f 3 feet: Water table depth SEPTIC TANK ❑ Typa/Mfg Capacity No. Compartments I PKG. TREATMENT PLT. ❑ :I�, Method of Disposal k Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED C, Distance to nearest: Well Foundation Property Line J� SEEPAGE PITS 11 pepth r Sire �` Number I SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS © 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 rules and regulations of the San Joaquin County Home owner or licensed ageni's signature canities 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 meaner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature 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- tion laws of California." Il Theapplicant u t call f r i r e inspe. " s. Complete drawing on reverse,side.. �l Signed Title: � <Ae`2 � / ___ Date: I df F T USE ONLY rr Application Accepted by i Date '–1 Area Pit or Grout Inspection by I� Date - Final Inspection by _5 Date Additional Comments: Applicant – Return all copeato: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE I INFO AMOUNTDUEAMOUNT REMITTED CASH RECEIVED BY �f DATE PERMIT'NO. , III a EH 13.24 1REV.1/R5 I V V ` f :LAO EH:426 — II