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II` 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 95201 2EMIT EXPIRES 1 YEAR FROM DATE ISSUM (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. Job Address City �Q C� Lot Size/Acreage Owner's Name CCI k- ,10LA2 va ;•,,ddress D b IJV �� Phone l f � Contractor Address, _��`q �lT Al-License No, Z sc�>-�Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0- DESTRUCTION X Out of Service Well ❑_ M PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitdring Ndil [7 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 L1 Industrial D Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications - f'1 Public Cl Other 1-1 Delta Depth of Grout Seal Type of Grout I i Irrigation _.Approx, Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction Well Diameter // Sealing Material b Depth Depth � Filler Material b Depth � � TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRlADDITION I I DESTRUCTION I I (No Septic system 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 KG. TREATMENT PLT. C1 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll 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 taws 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." The app' nt must caN for all required inspections. Complete drawing on reverse side. Signed t Title: Date: DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Z Date4*1-1 Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services y 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 ZIE�� AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO, }� CASHEH 14.20 IREv.1iM5> U,o o m2,EH 14�2p !