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APPLICATION FOR PERMIT f7' � SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PER1dIT EXPIRES 1 YEAR FROM DATE ESEPER (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 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. /rte /Job Address ...._J i� _ City[)ZOIC/CrOIY Lot Size/Acreage Owner's Name Address AE ,T� _ Phone 6 2. Con lraclo( Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION o Out of service We11 ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLU. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing (.3 Domestic/Private Cl Gravel Pack 0 Tracy Type of Casing Specifications 11 Public 1:1 Other l-1 Delta Depth of Grout Seal Type of Grout I # Irrigation —Approx. Depth I ) Eastern Surface Seal Installed by r Repair Work Done L3 Type of Pump H.P. I State Work Done Well Destruction ❑ Welt Diameter Sealing Material & Depth _ Depth Filler Material & Depth " TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTIO INo septic system permitted if public sewer is available within 200 feet.) installation will serve: Residence— Commercial_ Other t 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 1 k LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size _ Number SUMPS C1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ,I-hereby certify thaE I have-prepared-this application and that the work will be done in accordance with San Joaquin county ordinances, siatalaws, and 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,taws of California." Contractor's hiring or sub-contracting signature certifies the followin : "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 C rnia." The applic t must call or all requir ens ctions. Complete drawing on reverse side, C� _ Signed Tide: �J�' — ^ Date: FOR DEPARTMENT USE ONLY Application Accepted by !! Date Area Pit or Grout Inspection by Date Final Inspection loDate L Additional Comments: 7/- 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 FEEAMOUNT DUE AMOUNT REMITTED gSFt RECEIVED BY DATE PERMIT'NO, INFO F (� . EH 13-24(REV.I/n 5) EH',4.20