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APPLICATION FOR PERMIT l SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERUEXP RES 1 YEAR FROM D E (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. 51+9 and 1862 and the Rules and Regulations of San r Joaquin County Public Health Services. I A Cit QJCJL9�] r,\' y Lot Size/Acreage Job Address/9 V 1 .. t Phone - Owner's Name � p Address 'i ' cva�u �P License No. 3a�da� Phone ` 'S�CiJ ;y,' Caniract � Va ddress Ser TYPvice Well E OF WELL/PUMP: I�. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION C1 I Moniitori;ng Well ❑ rf i SYSTEM REPAIR ❑ OT1�Efi❑ r ❑ + ;.. l s r . PUMP INSTALLATION ❑ t DISTANCE'TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP LINE FOUNDATION AGRICULTURE WELL OTHER WELL PIT5/SUMPS41 _��.. A INTENDED USE+ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C1 fndustnal ❑ ,Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I Dot } 0 Gravel Pack L7 Tracy Type of Casing Specifications i f.a DomesticlPrivate • Type of Grout I'1 Publlc,'w ,`: #1 Other [� Delta Depth of Grout Seal .:Approx. Depth t I Eastern Surface Seal Installed by Repair Work Done . .L] Type=of Pump H.P. State Work Done r., Sealing Material,;&Depth Well Destruction C3 well , • My Depth Filler Material & Depth ' TYPE OF SEPTIC WORK: NEW INSTALLATION I I EPAIRI DDITION DESTRUCTION l I (No septic system permitted if public sewer is e available within 200 feet.) Installation will serve: Res/'idence�' Commercial Other.. r. j Number of living units: _ r Number of a rooms d. ' Sa ✓ � Water table depth Character of soil to a depth of3_feet: t SEPTIC TANK. Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT.❑ .. r � r I Method of Oitposal Distance to nearest: Well � Foundation �_ Property Lina f[ Totaength/size LEACHING LINE I No._& Lel l ngth of lines , FILTER BED 01 Distance to nearest: Well Foundation s Property Line _ SEEPAGE PITS 11 Depth $ =Size X46--7_ `. Y Number SUMPS = *"jar w Distance to nearest: Well, Foundation � } -Property Line a —. DISPOSAL PONDS -.� I hereby certify that I have prepared this application and that the work will be done in accordance with-5an Joaquin county ordinances, state laws,Aan i rules and regulations of the San Joaquin County 1 Home owner or licensed agelit's signature certifies the following: ''I�certify-that-immthe performance of the work for which this permit is issued,I'shaA not employ any person in such rtanner:as to become subject to workman's compensation laws of California." Contractor's hiring or sub contracting signature certifies the fallowing: "I certify thet.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." i �1= The applicant ust call for all req i .Gtons. Complete drawing on reverse side. l . Title: V. T • Date: Signed I FOR DEPARTMENT USE ONLY Date .4— I � r �- Area —P fin��epted by 2��`"''' tem` �� Final Inspection Iayu�`� Oatror Grout Inspection by Additional Comments: �I Applicant w Return ellt1 opiea to: Sen Joaquin County Public Health Services, Enviroamental;Health Permit/Services I 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BCK 9Y DATE PERMIT NO. INFO a EH 13-241r1EV.i/KSI I �L9 e LJ 1 V qG EH 14mM II �