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APPLICATION FOR PERMIT I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete is Triplicate) Application ie 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 i Joaquin County Public Health-Services. p „ + Job Address City Got Size/Acreage r Owner's Name Add -13 D .- ,l/ YPhone -3 4. ,��c�..l+�•wrt. - .aww.a.rrr.• � � .tip.�..- � Contractor dress � cense No Phone TYPE Of WELL/PUMP: NEW W LL O'L WE PREPLACEMENT 0 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ YSTEM PAIR ❑ OTHER O Monitor ng We l ❑ ! f DISTANCE TO NEAREST: SEPTIC TANK } � :SEWER LINES DISPOSAL FLD. PROP. LINE .' FOUNDATION f s AGRICULTURE LL OTHER WELL PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREA C STRUCTION SPECIFICATIONS C7 Industrial ❑ Open Bottom ❑ Manteca is of Well Excavation Dia. of Wel! Casing f D Domestic/Private ❑ Gravel Pack ❑ Tracy Typ -of-Casing '" Specifications t I'1 Public i-1 Other n Delta De h of Grout Seal Type of Grout 4 # I I Irrigation _ApproK. Depth I I Eastern Su ace Seal Installed by Repair Work Done U Type of Pump H.P. ''`State Work Done _ Well Destruction ❑ ` Well Diameter Sealing Material &`Depth Depth Filler Material & Depth I"^" 1 �Y TYPE OF SEPTIC WORK: -,NEW INSTALLATION 1r REPAIRIADDITION i I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve; Residence Commercial— Other I Number of living units Number of bedrooms ! �"" i Character of''soil to a depth of 3 feet: 4Water table depth SEPTIC TANK `/0 Type/Mfg ! Capacity No. Compartments PKG. TREATMENT PLT. Cl ' Method of Disposal Fti Distance to nearest: Well Foundation � � � Property Line r LEACHING LINE ❑ No. & Length of line 4 Total!length/size CAU &r FILTER BED 0 Distance to nearest: Well Foundation- l Property Line _pp � V f SEEPAGE PITS 11 Depth Tito' � `""iNumber - E SUMPS LI Distance to nearest: Well Foundation Property Line t DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, ands rules and regulations ot7he San Joaquin County t i 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 notl t employ any person in such manner as to become subject to workman's compensation laws of California."'Contractor's hiring or sub-contracting signature i certifies the following: "I certify that in the performance of the work for which-this permit is issued, I shall bmploy persons subject to workman's compensa- tion laws of California." # I The applica ust call feat required •nspections, Complete drawing on ieverse side. ►' y.y' i ' r Y F l Signed X Title: P� Date: R DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Graut_Inspect on by Date Final Inspection by I� . Additional Comments:. r 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 !NIF FE AMOUNT DUE AMOUNT REMITTED CK a ASH RECEIVED BY DATE PEftma'NO, S EH,?x.78 '"r;