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:u APPLICATION FOR PERMIT SAN JOAQUIN COUNTY -PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468--3420 SAN10AQ SUM. (JM1K 009, STOCKTON, CA 95201 � ZRMONMBN ALEMMDMUON RES 1 YEAR FR DAT ED SPECIAL P (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 CountyPublic Health Services. Job Address `r!aa f L Cit ocs�' -611 Lot Size/Acreage, Owner's Name J Cl Address Phone Contractor I/I L (�fO.Address 1A e AA in k,)m 1- S 'S License Nt,.Ss� Phone TYPE OF WELL/PUMP: NEW WELL ©' WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ F PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 Monitoring Well es r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES i DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I,/ C1 Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Weil Casing Al- ' C.l Domestic/Private- ❑ Gravel Pack ❑ Tracy Type of Casing 9 Specifications. r` 21) ' V1 Public +. f-1 Other fl Delta Depth of Grout Seal Type of Grout I I IrrigationP —.Approx. Depth l 1 Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done Weil Destruction ❑ Well Diameter Sealing Material Depth Depth Filler Material b Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION 1 I DESTRUCTION I I iNo septic system permitted if public sewer is 1 available within 200 feet.! Installation will serve: Residence— Commercial_ Other t Number of living units: Number of bedrooms �! Character of soil to a depth of 3 feet: Water table depth S✓ SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS CI Distance to nearest: Well Foundation Property Line i DISPOSAL PONDS 0 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 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 of 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 cal for all r uired inspections. Complete drawing on reverse side. Signed 0-1 Title: Date: I� FOR DEPARTMEN74SE ONLY • Application Accepted by Date �r rea Pit or Grout Inspection by Date Final Inspection by Date �1 Additional Comments: Applicant — Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., PLO Box 2009, Stockton, CA 95201 FEE' I AMOUNT DUE AMOUNT REMITTED CASH RE ED By GATE PERM17'NO. INFO . EH 13-241REV.iinsi '-v EH",1.20