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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRON MNTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , . PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXP RES 1 YEAR FROM DATE ISED f (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 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. f Job Address oZ`f#? `a Ado c� City �'S�'!A--J Lot Size/Acreage Owner's Name .f h,� (--�r o Lf — Address Phone L. � Contractor LG4j - h*-� ddress ��/ (� f�V��"� ��- License No.�3G� L_ Phone to 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 DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cf Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications t'1 Public to Other fl Delta Depth of Grout Seal Type of Grout 11 Irrigation —.Approx. Depth I 1 Eastern Surface Seat Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Al Well Destruction ❑ W0 Diameter Sealing Material & Depth O Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION l REPAIR/ADDITION I i DESTRUCTION # I iNo septic system permitted if public sewer is available within 200 feet.1 r Installation will serve: Residence L— Commercial_ Other V Number of living units: I Number of bedrooms__3 _^ e Character of soil to a depth of 3 feet: Water table depth d SEPTIC TANK fid'' Type/Mfg Capacity 0 No, Compartments 21 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 6 Length of linesTotai length/size Y O a FILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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." I The applicant must call for all required inspections. Complete drawing on reverse side. Signed Title: Date: r F DEPAPTMENT USE ONLY Application Accepted by Date /,111-0 Area �� Final Inspection b Data Pit r Grout inspection by Date Y Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services f 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY GATE PERMIT'No. CASH INFO /� r EH 13-24IREV.I/K51 .�� Q. oa [u 04 412E