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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION F 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O 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. Job Address .._3 City 6-'76Lj Lot Size/Acreage Owner's Namex� r Address I Phone — 1 7 7 ' Contractor C Address - R' License 46 J 3 7-3 Phone 6�- fb TYPE OF WELLIPUMP: NEW WELL ❑ WELL,REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well [3 DISTANCE TO NEAREST: SEPTIC TANK —,.SEWER LINES r DISPOSAL FLD. PROP. LINE FOUNDATION %r'AGRICULTURE WELL., OTHER WELL PITS/SUMPS ^� INTENDED USE TYPE OF WELL .,-' PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Inoustriai ❑.Open Bottom C3Manteca Dia. of Well Excavation Dia. of Well Casing 17] Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications Il Public, El Other + Cl Delta Depth of Grout Seal Type of Grout � 11 Irrigatron Approx. Depth I I Eastern Surface Seal Installed by Repair WorliyDone f L] v Type-af.Pump. _-__ H..P - 3 f > —.State Work Done.. Well Destruction ❑ Well Diametei- Sealing Material & Depth i 7 DBpth Filler Material 8 Depth; r __�T-YPEIOF-SEPTIC WORK: NEIN INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION l 1 [No septic system permitted if public sewer ii-`' i s available within 200 feet.+J t Installation will serve: Residence_iM Commercial_ Other i Number of living'units: i Number of bedrooms Character of soil.to`a depth of 3 feet: i ' i Water table depth SEPTIC TANK CIType/Mfg Capacity .kms No. Compartments PKG. TREATMENT PLT. ❑ .� Method of Disposal ' Distance to nearest:, WellFoundation "� Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED 1-1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size i Number SUMPS (l Distance to nearest: Well Foundatiori I 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 persons subject to workman's compensa- tion laws of California." 1 - The applicantust call for fall required inspections. Complete r drawing on (averse side. {_ n Signed X__(� G'L- ✓ / itle: Date: 1 R DEPARTMENT USE ONLY r Application Accepted by Date____ % Area Pit or Grout Inspection by Date Final Inspection by 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 FEE CK I INFO AMOUNT DUE AMOUNT REMITTED r CASH RECEIVED BY DATE PERMIT NO. . EH 13-241REV.tin 5) r 3