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3,UO APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 P O BOIL 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) i 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 P{ub'+lic Health Services. 8 Job Address City of Size/Acreage Owner's Name Address T �© i . Phone V}Conlractot i ddress se Nol22 "27 Phone L✓ y ` ,-TYPE bF WELL PU P: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 ! DISTANCE TO NEAREST:-SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial r ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Ca Domestic/Private ❑ Gravel Pack L1 Tracy Type of Casing Specifications F1 Public Cl Other f7 Delta Depth of Grout Seal Type of Grout + I Irrigation —Approx. Depth I i Eastern Surface Seal Installed by J Repair Work Done 0 Type of Pump H.P. State Work Dane_ Well Destruction ❑ Well Diameter Sealing Material & Depth i Depth Filler Material epth TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIR/ADDITION Wr DESTRUCTION I I (No septic system'permitted if public sewer is available within 200 feet.) Installation will serve: Residence v,.._ Commercial_ Other' Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table'depth 00 SEPTIC TANK. d Type/Mfg Capacity No. Compartments �� PKG. TREATMENT PLT. ❑ �` ' Method of D1 i posal Distance to nearest: Wet�� Foundation Property Line Arr LEACHING LINE L-) No. & Length of{lines Total length/size j FILTER BED D Distance to nearest: eEI _ Foundation r Property Line SEEPAGE PITS 11 Depth --Size- """ `Number f SUMPS LI Distance to nearest: WelyA1n_ Foundation _ Property Line DISPOSAL PONDS ❑ I hereby certify that I have preparad 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 r 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 + certifies the following:,"I cerfity that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- 7 tion-laws of California."' - } The applicant must cal r al aqui ad i s clions. Complet d wing on reverse side. Sig d X TitleDate: f { € R DEPARTMENT USE ONLY I Application Accepted by .CG.�c - �SU.hrt-.r�i.n_ __ _—_ DateArea A Pit or Grout Inspection by Date Final trispection by Date �6 �p )Iii Additional Comments: Applicant Return all copies to: San Joaquin County Public Health i Services, Environmental Health Permit/Services _ 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 • FEE MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. r INFO ; EH 13.2 tREV,tir5si �O�"`-' EH 926 �; 11 II