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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 BOX 2008, STOCKTON, CA 95201 � r PERIdIT EXPIRES 1 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 I 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. f-&,& �,� Job Address M?N �� ` t — S Q3 -- City !1 hot Size/Acreage • a(0 _ Owner's Name Lea �� *T+lf+ '''Address Phone vO p� Contractor SID License fro. C-1 Phone q TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ [[M��onitpring well E� DISTANCE TO NEAREST: SEPTIC TANK 7 l OD SEWER LINES > SD t DISPOSAL FLD. PROP. L71VE i FOUNDATION 7 3oiof AGRICULTURE WELL X3—CD-L OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS q0 4 C} Industrial CJ Open Bottom Manteca Die. of iA44 Excavation__ fay Dia. of Well Casing C7 Domestic/Private Ll Gravel Pack ❑ Tracy Type of Casing Specifications i I'! Public Cl Other CJ Delta Depth of Grout Seal ID 90I Type of Grout U I I Irrigation _ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION i I INo septic system permilled if 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 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line n� LEACHING LINE C) No. & Length of lines Total length/size FILTER BED U Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS I] 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 cenifies 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 workmen'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, f shall employ persons subject to workman's compensa- tion laws of C The applic t must all for all required Er spections. Complete drawing on reLverqp side. Signed Title: Date: Lq� 0c:l FOR lDEPARTMIEN USE ONLY Application Accepted by DatArea / Pit or Grout Inspection by Date Final Inspection b Data r 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 C K H RECEIVED BY DATE PERMIT-NO. . EH 13-21fREV.ri9S� S 4 ' �/'p� t0k� EH 14.20 �A