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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 0 SOX 2009, STOCKTON, CA 95201 _PERMIT EXPIRE5I-1 YEAR FROM DATE ISSUED 5.3tr � _ � , (Complete in Triplicate) '� � Z Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein describe . This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address t �ity } Lot Size/Acreage r- Owner's Name AddressPhone w +k ContractozAddress603 License Nv Phone 1?7 2 TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION K SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r� D Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Komestic/Private ❑ Gravel Pack C7 Tracy Type of Casing Specifications i1 Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation �_ pprox, Deptth� ` f( II Eastern Surface Seal Installed by Repair Work Done C] Type of Pump 'SLt �3 H.P. 2, State Work DoneO /11L/1146,40 Well Destruction ❑ Well Diametr R e r Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I i (No septic system permitted it public sewer is available 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 ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE D No. & Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, ancr rules and regulations of the San Joaquin County 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 certify that in the pefformance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant st c or squired inspections. Complete drawing on averse side. (� Signed X Title: Lf Date: FOR DEPARTMENT USE ONLY 71q I Application Accepted by _yi _..__ Date �' Area v �� Pit or Grout inspection by Date Final Inspection by Date 7Z3 Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATEEj R{IPERMIT'NO. . EH 13.24 1REV.i i n s)rW 4! ' MQ- •OL I Eli 11.25