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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 • . s p M IT EXPIRES 1 YEAR FROM DATE 15SUED (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 862 -and the Rules and Regulations of San Joaquin County Public Health Services. I City t Size/Acreage Job Address Phone Owner's Name. r Address t C ont ractor 4cSS e No4 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT — DESTRUCTION ❑ Out of Service well SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well PUMP INSTALLATION C1 , DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 Industrial , ❑ Open Bottom ❑ Manteca pia. of Well Excavation Dia. of Well Casing D Domestic/Private 111Gravel Pack ❑ Tracy Type of Casing Specifications I'I Public 1-3 Other 11 Delta, .. j Depth of-Grout Seal . Type of Grout- 11 rout11 Irrigation — Approx, Depth l I Eastern l Surface Seal Installed by Repair Work Done ❑ Type of Pump, H.P. State Work Done Well Destruction w ❑ Well Diameter} Sealing Material & Depth DepthFiller Materiel!?ph TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAMIADDITIDN DESTRUCTION l I (No septic system permitted it public sewer is r� available within 200 feet.) Installation will serve: Residence Commercial^ Other r �i 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. ❑ Method of Disposal - Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size— FILTER BED ❑ Distance to nearest: Well Foundation Property Line �.L 1 SEEPAGE PITS 11 Depth Size Number SUMPS 0 Distance to nearest: Well io 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 subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all re uir d n".clions. Comp a drawing on rev si e. Signed X Title: Date: TMENT USE ONLY Date Area Application Accepted by - } Pit or Grout Inspection by Date Final inspection by / Date) e�1 4 k Additional Comments: + Applicant - Return all copies to: San Joaquin County Public Health Services, &vironmental Health Permit/Services 1601 S. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEEMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-N0. INF + �"l `EH 13-211REV.,Ins) E�''''tt � � EH 14-2E �D ��