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APPLICATIONFOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 95201 EXPIRES 1 YEAR FROM DATE ED (Complete in Triplicates) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is trade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. er City Lot Size/Acreage Job Address ............ 05: 3 7 Phone Owner's Name L rasa Phone Contractor Address License No. l TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ _ DESTRUCTION ❑ Out of Service Well Gl r OTHER ❑ Monitoring Well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ C7 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 pia. of Well Casing ❑ Type of Casing Specifications Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation C1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Graut 1'1 Public {1 Other fl Delta Depth of Grout Seal Depth I 1 Eastern Surface Seat Installed by 11 Irrigation —.Approx. i Repair Work Done v Type of Pump H.P. State Work Done _ Sealing Material & Depth Weil Destruction ❑ Well Diameter Filler Material & Depth Depot TYPE OF SEPTIC WORK: NEW YNSTALLATION la4 REPAIR/ADDITION 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 - Water table depth Character of soil to a depth of 3 teat: ~' � d No. Compartments cep - SEPTIC TANK 14 Type/Mfg Capacity. , . f Method nt Disposal PKG. TREATMENT PLT. Cl J� Distance to nearest: Well d 0 Foundation Property Line -�aiA1A,s Total length/size t LEACHING LINE No. & Length of lines �, .� If FILTER BED ❑ Distance to nearest. Wall 5_ Foundation_ Property Line 0�� fiSEEPAGE PITS ?(1 Depth _Size Number I SUMPS LI Distance to near`t: Well Foundation Property Line k DISPOSAL PONDS D I hereby certify that f 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 V ` 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 cnmpensa tion laws of Cafifofnia." The applican t call of all re uirVAn9S,Wc1ior1s, Complete drawing on revers id Signed X Title: Date: �- F f;:PARM T USE ONLY q Application Accepted by Date ^L � — Area P1 r Grout Inspection by at ��+fr G Final Inspection by ate Additional Comments: Applicant - Return all copies to: Ban Joaquin County Public Health l Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 2009, Stockton, CA 95201 EEE AMOUNT DUE AMOUNT REMIT'TE0 CK' RECEIVED BY DATE PERMIT'ND. INEa (� /� / F + Eµ13.241REV.I/R51 `rl� Ll 6 V.,s EH 74-26 (// PP