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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 0 BOX 2009, STOCKTON, CA 95201 -PERMIT EXPIRES' 1 YEAR FR M DATE LPSUEP (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. . �r ` / f City !/ of Size/Acreage Job Address C Phone Owner's Name f-L '-- -��— Address Contractor Address License No. Phone TYPE OF WELL/PUMP: -NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well Monitoring Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 R Industrial © Open Bottom C] Manteca Dia. of Well Excavation Dia. of Well Casing C.l Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications I'I Public C1 Other fl Delta Depth of Grout Seal Type of Grout I i Irrigation —.....Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ & Well Destruction ❑ Well Diameter Sealing Material Depth j Depth Filler Material b Depth I TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION 1 I DESTRUCTION iNo septic system permitted if public sewer is r available within 200 feet.) Installation will serve: Residence-- Commercial_ Other Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ,{1 PKG. TREATMENT PLT. C1 Method of Disposal L' Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 7 SEEPAGE PITS i I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS El Xl I hereby cenify 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 or subcontracting signature I` 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." IThe applicannt l<nu all for I requir inspections, Complete drawing on r se side. p j Signed X -1//1 mss. Title: Date: EPARTMENT USE ONLY Application Accepted by - Date �'^ L Ars Pit or Grout Inspection by Date Final Inspection byo Additional Comments: Applicant Return all copies to: Sara Joaquin County Public Health Services, Environmental Health'Permit/services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED f kjCW RECEIVED BY DATE PERMIT"NO. r INFO �] i • EH 13-24IREV.1"51 +v� i EH 14,26