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A. APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXP RES 1 YEAR FRPM DATE ISSUED (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 coupliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. 1 Job Address 2 SDtn} 1,q Eh�0 p-A -_ _ City 1C vN Lot Size/Acreage .9-5"Z— 9 31 2 Owner's Name Address q e T' Phone Contractor Address s License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION C] SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing C.1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Ul Public 1-1 Other [1 Delta Depth of Grout Seal Type of Grout I I Irrigation _.Approx. Depth I I Eastern Suriace Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth I Filler Material b Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I 1 DESTRUCTION I ] lNo septic system permitted if public sewar is available within 200 feet.I Installation will serve: Residence ✓ Commercial_ Other Number of living units: ----L Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg d2k^4T Capacity F6 0rf2-- No. Compartments PKG. TREATMENT PLT. ❑ � Method of Disposal Distance to nearest: Well S`GC____ Foundation Property Line 3 o LEACHING LINE ? No. & Length of lines — e"6 Total length/size FILTER BED ❑ Distance to nearest: Well Lt'7 Lt Foundation ! 5- Property Line 2 an � 5 SEEPAGE PITS 11 Depth Sire Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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 required inspections. Complete drawing on reverse side. Signed % N, tlxm - Title. Date: FOR DEPARTMENT USE ONLY Application Accepted by Date r i Area Pit or Grout Inspection by Date Final Inspection by Date 5 w Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 2009, Stockton, CA 95201 INFEE O MOUNT DUE AMOUNT REMITTED K H RECEIV D tit DATE PERMIT'[NO. . EH 13.24 IREV V EH.I-2e i 1 t