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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES y ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 I P O BOX 2009, STOCKTON, CA 95201 EXP RES 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 blic Health Services. Job Address City` Got Size/Acreage u Owner's Name Address Phone Contractor I�tJ_ [L74�� Address - License No. 43Z�ja_L Phone TYPE OF WELL/PUMP: ii NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION D Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR 0 OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. `- — PROP.TINE—.- FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing El Domestic/Private ❑ Gravel Pack 11 Tracy_a t Type of Casing Specifications------- ----- - I"I Public 1-7 Other n Delta Depth of Grout Seal Type of Grout I i Irrigation _..Approx, Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done _ Well Destruction O Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION 1 o septic system permitted if public sewer is available within 200 feet.l Installation will serve: Rosi ence ommercial_ then Number of living units: Number of bedrooms Character of soil to a depth of 3'feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartrnents PKG. TREATMENT PLT. ❑ Method of Disposal G Distance to nearest: Well Foundation Property Line LEACHING LINE CI ,. No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line r SEEPAGE PITS 11 Depth Size _ Number. SUMPS LI Distance to nearest: Well Foundation-=� Property Line DISPOSAL PONDS pot -- 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 at sub-contracting signature di-lies the following: ' certify that in the performance of the,work for which.lhis.permit is_issued,_I-shall.employ_persons.subject to workman's compensa- f u _ Cali ornia. ' a� The applica t -I call or a re red ' pe, an o to drawing on r verse si Title: ._._ -____ Date: r FOR DEPARTMENT USE ONLY A li Appcation Accepted by _ .Area - Y-AddPit or Grout Inspection by '° L� Date Final Inspection by_ �? � Data —2y- Additional itional Comments: Applicant - Return all copies to: San Joaquin County Public Health —Services i-Envii-onmental--Hea.lth..Permi't/ServiceEr-"- - 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. + EH 13-24 IREV.tin 5) EH 74.26 1.7 t4