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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 REMIT EXPIRES 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 Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address G City Lot Size/Acreage ^�- Owner's Name O� Address Phone � �. Centraclor Address /.�G� , rte __ License No, .25� Phone •Z TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 1-1 DESTRUCTION ❑ out of Service Well PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well C] 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 * Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing * Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I') Public El Other n Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I I Eastern Surface Sedl installed by �., Repair Work Done LJ Type of Pump H.P. State Work Done rw Well Destruction ❑ Well Diameter Sealing Material & Depth 9J Depth Filler Material & Depth Q\ TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADOtTION I I DESTRUCTION I I ]No septic system permitted if public sewer is \ available within 200 feet.) Installation will serve: Residence commercial_ Other Number of living units: I Number of bedrooms _ Character of soil to a depth of 3 feet: 6^ei- Water table depth SEPTIC TANK ❑ Type/Mfg Capacity.4=2ccdt> _ No. Compartments' PKG. TREATMENT PLT. ❑ — Method of Disposal i Distance to nearest: Well �� Foundation . c2 Oy _ Property Line _ i LEACHING LINE No. & Length of lines Total length/size - FILTER BED ❑ Distance to nearest: Well/Cr6-1- - Foundation �g�F, Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line ^" DISPOSAL PONDS ❑ t I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinancies,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 subcontracting signatur 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." The applicant must call for all equir d inspections. Complete drawing on reverse side. Signed Title: ��- -�i Date: FOR DEPARTMENT USE ONLY Application Accepted by Date r G Area Pit or Grout Inspection by Date Final Inspection by Date U Additional Comments: . 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 EE INFO AMOUNT DUE AMOUNT REMITTED ASH CK RECEIVED By DATE PERMIT'NO. . EK 13-24(REV,r/As) EK 1.1.1e l 4 a