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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 2009, STOCKTON, CA 95201 PERMIT 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 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. �L Job Address Lot Size/Acreage Owner's Name 0 Address Phone Contfactor Q r r f LZ1 Address f e a.,8,* `/Qt r9a!T License No.+5ZYE38_s Phone -.2 r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ 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 SPECIFICAT! NS r� 1} Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Z 0 Dia. of Well Casing ADomestic/Private Gravel Pack ❑ Tracy Type of Casing Ce / Specifications I"I Public Cl Other C-1 Delta Depth of Grout Seal r Type f Grouteeft", I I Irrigation cP3f� Approx. Depth l I Eastern l / rface Seal Installed by h Repair Work Done ❑ Type of Pump H.P. _.`_ State Work Done_ Wetl Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic syslem permitted 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. L) Method of Disposal Distance to neerest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ 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 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, 1 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:..' 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.l'' The applicant must call.for all requiredd iispections.-Complete drawing on reverse side. Signed Xz�k_A? `�r_1/r� �,� Title: Date: e� _&4tf0&1? F R DEPARTMENT USE ONLY '1 i Application Accepted by ko, - Date ` °vto ' Area Pit or o t Inapection by Date Final Inspection by Date 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 INFE A AUNT DUE AMOUNT REMITTED CK If CASH RECEIVED BY DATE PERM17N0. + EH13.24fREV.I)M51C),5D- /S97 E14 A-26 �- 11 S