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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 PEMIT 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 San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Addresses f �. D 1_ City Lot Size/Acreage lQ,7 Owner's Nam bYt0�tQl t�;l,e wLr Address AVas 1*2�Yr�� ,,,__,;/A-1 �ae.+10'l .na r Contract rr AddressPo License filo, 2 Z Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well D PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 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 Wel! Excavation Dia. of Well Casing ;:] Domestic/Private ❑ Gravel Pack C1 Tracy Type of Casing Specifications l'] Public (-I Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation — Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done T Well Destruction ❑ Wel! Diameter Sealing Material Depth Depth Filler Material b Depth TYPE OF SEPTIC WORK: NEW INSTAL hATION REPAIR/ADDITION ! I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.l Installation will-serve: Residence T Commercial_ ther Number of living units: Number of drooms l Character of soil to a depth of 3 feet: Water table depth Q' SEPTIC TANK Type/Mfg Capacity No. Compartments r PKG. TREATMENT PLT. ❑ 1 ( Method of Disposal t Distance to nearest: Wet] Foundation Property line as� � LEACHING LINE , No. & Length of linesTota] length/size O o� FILTER BED 0 Distance to nearest: Well — Foundation_ �D r Property Line F Ali SEEPAGE PITS Depth Size le. Number e SUMPS LI Distance to nearest: Well_4W Foundation /4 Property Line 7 DISPOSAL PONDS 0 I 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, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting 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." The applicant s all for allM inspections. Complete drawing an reverse si h Signed Title: Date: L� FOR DEPARTMENT USE ONLY �A+ppplication Accepted 6y Date Area 6i10 Grout Inspection by Date< � Final Inspection by. w �i_� Date 6 �. 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMITNO. 1 EH 13.24(REV.i i x 5f p 0 EHU-26