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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 O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISt � Ca (Complete in Triplicate) - a�b Application is hereby made.to San Joaquin County for a permit to construct and/or install the work herkn desert; -This application is made in compliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulative of SlSan � , Joaquin County Public Health Services.lF r ® 11 f,� U City (jLG]f�[7,h Lot Size/Acreage Job Address ) I ! ' Co I C/ F Owner's Name �f+' V r ` Address �t(o w t ` o V V"� �`V� Phone ��Y + • Q(c• e� Ce~` r�c�c 3�8�1 Contractor ddress tOPt License No. Phone TYPE Of WELLIPUMP: NEW WELL ❑ f WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 0 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 i f--1 Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing f7 Domestic/Private Cl Gravel Pack 0 Tracy Type of Casing Specifications I'I Public is Other fl 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, I Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK:. NEW INSTALLATION l 1 REPAIRIADDITION I I DESTRUCTION INo septic system permitted it 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. ❑ a Method of Disposal Distance to nearest: Well Foundation Property Line - a LEACHING LINE CI No. & Length of lines Total length/size) FILTER BED D Distance to nearest: Well f Foundation Property Line t t e SEEPAGE PITS 11 Depth Size r g Number 3 SUMPS CI 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 of sub contracting signature cartifiss 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." j t The appli ust c or all reqi ed inspections. Complete drawing on reverse side. I 4r� Signed ` Title: t ' '�— t Date: _ ~[ — r ) OR4WARTMENT USE ONLY I �j Application Accepted by W CI�C.=�_ -- -- Date ` 1 Area Pit or Grout Inspection by Date Final Inspection by Date D d Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave. R 0 Box 2009, Stockton, CA 95201 s FEE AUNT DUE AMOUNT REMITTED RECEIVED BY OATS PERMIT'NO. INF j� CASH �. . EH13-24(REV.tins) ��r71� ✓��" 1� EH 14.26