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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 r ,t PERMIT EXPI_RES-_1 YEAR FRQM_DA2:E IS5UED (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 Publiic,, Heal`th� rServices. �w k Job Address y 1� �/►��ST '"`"• "�` City Lot Size/Acreage +7� Owner's Name mi Address 1:2 . 1'4Qa►a Phone (� }'� License No, Phone 'S7� Contractor �� e�V'��Address . +" I�a� � TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Out of Service WeII ❑ 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 PR08LEM AREA CONSTRUCTION SPECIFICATIONS F1 Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing i C-1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 411 Public C3 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _..Approx. Depth I I Eastern Surface Seal Installed by � 1 Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction Cl Well Diameter Sealing Material & Depth ry r Depth Filler Material & Depth `y TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIR/ADDITION ( I DESTRUCTION l I (No septic system permitted if public sewer is (�\ available within 200 feet) Installation wilt serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity_ No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal ° Distance to nearest: Well Foundation Property Line t LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line �^ SEEPAGE PITS 11 Depth Sire Number SUMPS 0 Distance to nearest: Well Foundation Property Line a DISPOSAL PONDS ❑ ; F 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 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 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 must of a eq d ns tions. Complete drawing averse ss Signed X. cam. Title: rf + Date: FOR DEPARTMENT USE ONLY y Application Accepted by _ Area 1s_ Date �,r-L-� _; Pit or Grout Inspection by Date Final Inspection by AfNiker cis Date ba . (Ucrl "*ov-eLcf Additional Comments: ;s [ rS r r. Applicant – Return all copies to: San J SwSdrvt pp og Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 IEEE DUUNT DUE AMOUNT REMITTED C K�+H RECEIVED BY DATE GPERMITN2O. a EH 13-24(REV.rinse J t a� � � Q -1 o �l�✓� EH A-211 (Q iij