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I APPLICATION FOR PERMIT SAN J'OAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION _ , 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 NO f3L P11 RFRMIT EXPIRES_ 1 YEAR FROM DATE .ISSUED (Complete in Triplicate) t 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 1662 and the Rules and Regulations of San Joaquin County Public Health Services. I i Job Address City S Lot Size/Acreage Owner's Nam l Address „ Phone 4Z3- 31 I Contractor I� Address License No. Phone_ a TYPE OF WELL/PUMP; :'NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ ~ PUMP INSTALLATION D SYSTEM REPAIR ❑ OTHE ❑ Monitoring Well V [� DISTANCE TO NEAREST;-SEPTIC TaANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUND AGRICULTURE WELL OTHE L PITS/SUMPS i INTENDED USE TYPE OF,WELL PROBLr:'O EA CONSTRU PECIFICATIONS k i C7 Industrial ❑ Open Bottom ❑ Manteca Excavation Dia, of Well Casing N Domestic/Private ❑ Gravel Pack ❑ T _Type_of_Casing Specifications I') Public Cl Other �I Deltaf depth of Grout Seal^ Type of Grout I I Irrigation _.Ap epth I I Eastern Surface Seal installed by Repair Work Done L7 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter '' Sealing Material & Depth r Depth Filler Material & Depth t f TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I i DESTRUCTION)(INo septic system permitted if public sewer is 'iz available within 200 feet.) Installation wilLserve: Residence Commercial_ Other Number of�iiving units: Number of bedrooms { Character of soil to a depth of 3 fe is Water table depth I SEPTIC TANK. ❑ Type/Mfg Ca acit' No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal I 1 1 a t ., Distance tkb"'n Ere IMR I n• Property Line LEACHING LINE 0 No. & Length f;riVe expiredoral length/size f j FILTER BED Ll Distanceto t-lgle � �io> � a� � M1W:�l�l � _ Property Line 5 SEEPAGE PITS 1 I Depth bV nVli@qfn u..1 �„ .-.-- Number SUMPS . 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ , I hereby certify that l 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: "! 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 performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." r The applicant mu t- f for all req inspections.' tirtmplefe arawing ori reverse side. Signed ` 1 Title: Date:1�_� 9[ FO DEPARTMENT USE ONLY # Application b Accepted l P y Date � I ._.,_ Area } Pit or Grout Inspection by Date Final Inspection by Date 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 INFO AMOUNT DUE AMOUNT REMITTED CK CASH �HE�CEIVED BY DATE PERMIT'NO. « £H 3-241PEV.i/ s� 00 EH i -