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APPLICATION FOR PERMIT ' SAN J'OAQUIN COUNTY PUBLIC HEALTH SERVICES � .;'`; ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)458-3420 r P O BOX 2009, STOCKTON, CA 95201 fi PERMIT EXPIRES 1__YEAR''FR M 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. s Job Addres-e=7 City Lot Size/Acreage Owner's Name r �Ad$ress :� * M Phone �� Contractor Addres I r f �L License Nt Phon TYPE OF WELL/PUMP:s NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0-out-of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER © t Monitoring well C7 f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FI-D—__+PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL------,:—,PITS/SUMPS t Y _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f r M Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing f Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications \� I"I Public 1-1 Other C1 Delta Depth of Grout SealType of Grout \(tel , 11 1 Irrigation _..Approx. Depth I I Eastern Surface Seal Installed by R �} Repair Work Done LJ Type of Pump H.P. State Work Done, f .4-Weil Destruction 0 Well Diameter Sealing Material & Depth -� Depth Material & Depth TYPE.OF SEPTIC WORK: NEW INSTALLATION [ I REPAIR/ADDlYtO DESTRUCTION I I INo septic system permitted it public sewer is available within 200 feet.) I. Installation will serve: Residence Commercial--'` Other Number of living units: 4— Number of bedrooms` r Character of soil to a dgpth of 3 feet: _ Water table depth ` SEPTIC TANKZD(I ❑ Type/Mfg Capacity No. Compartments (' PKG. TREATMENT PLT. ❑ Y Method of-Disposal .' Distance to nearest: Well Foundation Property Line''%t' u s7 LEACHING LINE .NoY& Length gfJlin's '� r y Total length/size--4-n-, " r FILTER BED ❑ Distance to nearest: Well Foundation _ __ Property Line k SEEPAGE PITS SCI S�1 1 Depth Size Number V_ SUMPS LI Distance to nearest: Well Foundation Property Lind .r r DISPOSAL PONDS ❑ i .* 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 i rules and regulations of the San Joaquin county { e.. 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 law's 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." ' F The applicant c for all requi inspe ions. Comple drawing erse side. k1 ///�' Signed Title: Q .' ,. Date:��L5� � FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspa tion by &1 4 Date- Additional ate Additional Comments: 1/ Applicant - Return all cop ea to: San J in County Public Health Services, Environmental Health Permit/Services ri 1601 E. Hazelton Ave., P 0 x 2009, Stockton, CA 95201 FEE INFO AMOUNT Dt)E AMOUNT REMITTED CA ECEIVED BY ATE i _ PERMIT'NO. a EH11-Ze 3.2 IREV.1/N 51 � EH 2 t 1