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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$--3420 P O BOIL 2009, STOCKTON, CA 95201 a REMIT 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 Ho. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Servic ✓ Job Address �__ ..,_,� City Lot Size/Acreage ...L ' Owner's Name =_ -___ '� G1/d7L�t' Address __ ��'�` _ Phone d Contractor Address License No. Phone TYPE OF WELL/PUMP:. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 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 _ I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i n Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Weil Casing Cl Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public C1 Other I-1 Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L] Type of Pump H.P. State Work Done _. Well Destruction ❑ Well Diameter Sealing Material A Depth Depth Filler Nateri 8 Depth TYPE OF SEPTIC WORK: NEW INSTAION I 1 REPAIRIADDITIO DESTRUCTION I i INo septic system permitted if public sewer is t available within 200 feet.) Installation will serve: Residence— Commercial Other 401M �• Number of living units: Number of/�b_�edd�ro``om_s Character of soil to a depth of 3 feet: ryL �" 'r Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, ❑ ` Method of Disposal Distance to nearest: Well Foundation Property Line LEA NE D No. & Length of lines Total length/size ILI fTE BED ❑ Distance nearest;, II Foundation Property Line SEEPAGE PITS It Depth f- Size Number SUMPS U 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, 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 persona subject to workman's compensa- tion laws of California." The applicant m t all for all required inspections. Complete drawing on reverse side. C� Signed Title: Date: R DEPARTMENT USE ONLY Application Accepted by DateArea Pit or Grout Inspection by Date Final Inspection by gj&&&A,_ Date i Additional Comments: ud l0� 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 INFOMOUNT DUE M/OUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. 14 ef+ EH'3.26[REV.i i n sr �/A/ ��.EH��Iti //