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API�LICATION 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 EXPIRES 1 YEAR FROM DATE ISSUED (Complete is 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 Public Health Services. r;0,F�e,# - Job Address t � eCCity Lot Size/Acreage a Owner's Name Address Phone j Contractor 15dress icense No. / Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION4 SYSTEM REPAIR ❑ OTHER CI Monitoring Well C1 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 SPECIFICATION4 I1t F1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private Gravel Pack 0 Tracy Type of Casing Specifications I'l Public / fl_1 rO�ther n Delta Depth of Grout Sea] Type of Grout s-- I 1 Irrigation JOApprox. Depth I I Eastern Syt1 ace Seal Installed by Repair Work Done 0 Type of Pump � H.P. State Work Done _ Well Destruction C1 Well Diameter Sealing Material & Depth Depth Filler Material 5 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR IADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will 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. 0 Method of Disposal Distance to nearest: Well Foundation Property Line Q LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size ^`Number SUMPS Ll 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 ompensa- tion laws of California." The applicant m c Ap ired i c omplete drawing on revers e. � 7 Signed X le: 44�e Date: DEPARTMEN!I T USE ON Application Accepted by Q'�'-`- o • ^-'"� ._._ Date Area Pit or tout 1 pection by Date pection b - Date f Final ins f y Additional Comments: ` t C, �" e Applicant - Return all copies to: San Joaq.in County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH 41ld 11 . EH 13-24 IFIEV.r/M 51 f,� t �: � a ' i EH 4.2e 111