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APPLICATION FOR 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 D (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 1662 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address _�r �—�`�/U City Lot Size/Acreage l �� t Owner's Name 17' [ v e Address Phone Contractor Address " "' License No Phone.. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ out of Service Well 0 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 LI Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1-1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Il Public., C7 Other n Delta Depth of Grout Seal Type of Grout " '1 I Irfioation _.Approx, Depth t I Eastern Surface Seal Installed by �- Repair Work pone 0 Type of Pump H.P. State Work Dona _ Well Destruction ❑ Well Diameter Sealing Material & Depth ,Depth Filler Material & Depth TYPE OF SEPTIC WORK:—NEW INSTALLATION. REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is available within 200 feet.) Installation will-serve: Residence -! Commercial_ Other Number of living units: '1 Number of bedrooms .Y _ Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. Cl Type/Mfg �.�� _ _ Capacity No. Compartments PKG. TREATMENT PLT, ❑ Method of Disposal Distance to nearest: Well Foundation��z— Property Line U LEACHING LINE No. & Length of lines _ a-0- -- . Total length/size FILTER BED 0 Distance to nearest: Well j Foundation Property Line -- Cj SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well` Foundation Property Line DISPOSAL PONDS 0 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�i rules and fegulation�of the San Joaquin County s 1 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+vorkman's compensation laws 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." The applicant must call for all quired inspections. Complete drawing on reverse side. Signed Title: .. 4 iL Date: '11`01�,MEPARTMENT USE ONLY.-. Application Accepted by Dat ApolQ Area 1 7— Pit or Grout Inspection by Date Final Inspection by Date 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 IN 0 AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE :AERMI7'N0. a EH 1321[REV.1/nel EH 41.26 t's,.