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APPLICATION FOR PERM I i t SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES f ENVIRONMENTAL HEALTH DIVISION " ` `r 1601 E. HAZELTON AVE, , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 ' k # PERMIT EXPIRES .1 YEAR FROM DATE ISSUP (Complete in Triplicate) f 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 Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San . Joaquin County Public Health Services. . Job Address r • City * Lot Size/Acreage- Owner's ize/AcreageOwner's Name Address - Phone Contractor_' - Address J r License No.! ..-, Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD: PROP. LINE ' FOUNDATION AGRICULTURE WELL OTHER DELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION-SPECIFICATIONS k n Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well'Casing F.) Domestic/Private ❑ Gravel Pack L7 Tracyo- Type.of Casing Specifications 1'1 Public �. 1-1 Other n Delta Depth-of Grout Seal .. Type of Grout 4. I 1 Irrigation _Approx. Depth` I I Eastern Surface Seal Installed by Repair Work Done '.,.0 Type of Pump H.P. t State Work Done_ Well Destruction '- ❑ Well Diameter Sealing Material & D6pth µ - Depth Filler Material A Depth "' r TYPE OF SEPTICr WORK: .-NEW INSTALLATION f I REPAIR/ADDITION ) DESTRUCTION Id (No septic system permitted if public sewer is available within 200 feet.I / Installation will serve: Residence_ Commercial— Other ' Number of living units: Number of bedrooms` t i Character of soil to a depth of 3 feet: �' .:` '• t � �-,,J ' Water table depth T SEPTIC TANK CI Type/Mfg Capacity ' No. Compartments PKG. TREATMENT PLT. 0 ' Method of Disposal Distance to nearest: well f Foundation Prop;rty Line r F ! J. LEACHING LINE , Cl No. & Length of lines 6Total length/size FILTER BED ❑ Distance to nearest: well Foundation _,m4r-90 Property Line d r t :. SEEPAGE PITS II Depth Size __Number P SUMPS LI Distance to nearest: Wel! /rQa '� Foundation d Property Line Z� _ µ DISPOSAL PONDS p 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 rules and regulations of the San Joaquin County s 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, 1 shall not employ any person in such manner as to become subject to urorKman's compensation laws of California." Contractor's hiring or sub-contracting signature r certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persona subject to workman's compensa- tion laws of California." i ti I The applicant must or It req Ins io Complete drawing on reverse side, Signed X Title ,— - ... _ k ,� -Date Sr �� J FOR DEPARTMENT USE ONLY Ap Ii lion Accepted by 3 Date I. Pi or Grout Inspection by — Date `r /Final Inspection by ate ._ Additional Comments: I Applicant - Return a.11 copies'to. Joaquin County Public Realth .z, Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE t INFO AMOUNT DUE AMOUNT REMITTED CK 10 ASH RECEIVED BY DATE PERMIT,NO:. t . EH 13-241REV.iinsi 7�&4o EH 14.26 i i I