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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 98201 PFRUIT-EXPIRES 1 YEAR FROM DATE ISSUBP1�t i (Complete in Triplicate) t Application is hereby trade to San Joaquin County for a permit to construct and/or install the work herein des ribed. 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. 1 Job Address,_,2a1 ,-,2a CityLot Size/Acreage f Owner's NamePZ6 ddress Phone Contractor Address License Pio. Phone PE OF WELL/PUM - NEW WELL ❑ WELL REPLACEMENTm C_1 DESTRUCTION ❑ Out of Service Well ❑ 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 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing j fa Domestic/Private ❑ Gravel Pack ❑ Tracy' ,Type of Casing 'Specifications 1 i'1 Public ' '' i-1 Other n Delta Depth of Grout Seal Type of Grout I Irrigation Approx. Depth l I Eastern Surface Seal installed by ' Repair Work Done 0 Type of PumpH.P. 1 State Work Done Well Destruction O Well Diameter A* Sealing Material & Depth R Depth Filler'Naterial & Depth ri TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION^ INo septic system permitted if public sewer is ' available within 200 feet.) Installation will serve: Residence— Commercial_ Other w 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 4 Cl No. & Length of lines Total length/size FILTER BED FI Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation . -_ Property Line DISPOSAL PONDS C 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 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 of sub-contracting signature t cenifies 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." ��The applic m t call fof all % ction Complete drawing on r arse side, i JJ�Signed X Title: Date: ` S fi EPAIRITMENT USE ONLY Application Accepted by_ Date Area Pit or Grout Inspection by Date Final Inspection by Dats� �U I 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 AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH 4 EH 13-24 IREv.tin5> f EH 14.26 / r I -gyp.