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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1641 P•0HAZELTON BOX 2009`,VE. , PHONE -3420 STOCKTON, CA 95201 i EXP RES 1 YEAR FROM DA E ED (Complete in Triplicate) to construct and Application is hereby made,to San Joaquin County for a permit application.,ia made in compliance with Ban Joaquin County Ordinance No. 51+9 andd install the work herein described. This 1862 and the Rules and Regulations of San 1 t Joaquin county Public Health Services. r +� City Lot Size/Acreage Job Address Phone Owner's Address i V I Owner's Name � �. r Address d License No.agig Phone_ Contracts DESTRUCTION ❑ Out of Service Well ❑ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ Monitoring Weil [I SYSTEM REPAIR 0 OTHER ❑ II t PUMP INSTALLATION ❑ _ I SEWER LINES- �--- DISPOSAL FLD. PROP, LINE DISTANCE TO NEAREST: SEPTIC TANK __�— PIT$/SUMPS I r; t FOUNDATION __�_�— AGRICULTURE WELL OTHER WELL— INTENDED-USE-- TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia, of Well Casing l [.i Industria! ❑ Open Bottom ❑ Manteca Dia. of Well Excavation i i i ^' t.7 Tracy Type of Casing Specifications- ❑ Domestic/Private. Cl Gravel Pack - Depth of Grout Seal e'Type of Grout I'i Public f l.1 Other Cl Della Approx, Depth I I Eastern Surface Seal Installed by 1 I I Irrigation State Work Dana — Repair Work Done' L7 Type of Pump H.P. Sealing Material & Depth Well Destruction ❑ Well Diameter Filler Material & Depth Depth RK: NEW INSTALLATION I'I REPAIR!• 03111 N I �.Ni ESTRUCTION l I availabllelw thin 200 feet.)stem it public sewer is TYPE.OF SEPTIC WO installation will serve: Residence Z Commercial---,,)Other •ti Number of living units: Number of roams l 4. ,'+E 'Water table depth Character of soil to a depth of 3 feet. r + ' -+ No.-Compartments t Capacity__- _' SEPTIC TANK. 13 TypelMtg ! 1 Method of Disposal PKG. TREATMENT PLT. ❑ t . Property Line .! i Distance to nearest: L Well Foundation . . t �' r l - f Total length/size 'r LEACHlNG.LINE ` No. & Length,of lines , BEd { i O Foundation k0 Property Line FILTER BED t.7 Distance to nearest: } , Well ` t �1 , r - r/ Size X v+ Number SEEPAG f E PITS l 1 Depth Y �-- Distancle to nearest:! Well_.�1-- Foundation Line - � 1 SUMPS C g - 4 ... .: .} ` r DISPOSAL PONDS ❑ _ .-- --_ - - - t I hereby oeAify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, slate 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 became subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following;'9 certify that-in the performance of the work for which this permit is issued, I shall employ parsons subject to workman's comper% 4 tion laws of California." 1 The applicant mu call for al qu'ed inspections. Complete drawing on raversasiP , Signed I Title: }�/} Date: f n R DEPARTMENT USE ONLY v - ` Date Area Application Accepted by Date - Final Inspection b Date rk Pit or Grout Inspection by ! Additional Comments: Applicant - Return all copies to: San ioaquinn County Public Services, 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE CK RECEIVED BY DATE PERMIT�NO. INFO AMOUNT DUE AMOUNT REMITTED CASH // p . EH 13-24 IREV.i/A s7 �� " O EH 14-Ze