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i APPLICATION FOR PERIL I T �; T SAN JOAQUIN COUNTY-PUBLIC--HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 3.501 E. HAZELTON AVE. , PHONE (209)468-3420 f ¢" P O BOX 2009, STOCKTON, CA 95201 ' i , MIRES 1 YEAR FR M DATE'1§§WMD (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. 519 and 1862 and the Rules and Regulations,of.San Joaquin County Public Health Services.,,.. �` E i ) rc City Y" Lot Size/Acreage Job Address r d 1C1 .P_ _ Address"y 12" Phone ` Owner's Name .y - Contractor C _Address �� d�7 a��.. License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 17DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALI.ATION,jC SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ 11 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION °il AGRICULTURE WELL OTHER WELL PITS/SUMPS T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n industrial '.'❑ Open Bottom : C1 Manteca Dia. of Well Excavation Dia. of Well Casing (l Domestic/Private =" _C1 Gravel Pack ❑ Tracy Type of Casing Specifications ' I'l Public [-I Other-- rl Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I i Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done Iti { F fl Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK; 'NEW_INSTALLATION REPAIWADDITION I I• DESTRUCTION-[ I availablelw thin 200 feet.) it public sewer is s , / Installation will serve:` Residence t! Commercial Other � Number of living units: _ Number of bedroom r,r � v � Character of soil to s'deplli of 3 feet: ��*� `-1 ey r�L.- -- —Water table depth s I� w .. a CQ 6_ No. Compartments SEPTIC TANK. � IQ :.Type/Mfg Capacity PKG, TREATMENT PLT. ❑ �, Method of Disposal Distance to nearest: Well J�.,._ Foundation Property Line IS LEACHING LINE 1 t N & Length of lines 3 _- _ Total length/size ,r....o� FILTER BED Cl ::Distaarrceto nearest: Well p�Sh� Foundation _3S Property Line ^ SEEPAGE PITS .Depth 14-r -- ._-Size Number - - SUMPS L1 'Distance to nearest: Well L!t23 Foundation� Property Line _ DISPOSAL PONDS ❑ �• t 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 I certifies the following: "I certify that in the performance oi,the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." L: --I The applicant must call for all req ad ed inspections. Complete d wing on reverse side. Signed X Title: Date: `v FOR DEPARTMENT USE ONLY s j Application Accepted by ' Date o Area Pit or Grout Inspection by I Date Final Inspection by Date Additional Comments: -- 4 t Applicant - Return all copies to: San Joaquin County Public Health'r. `,Services, Environmental Health_Permit/Services Ha 1601 E. zelton Ave., P-O-Rwx 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK A CASH t RECEIVED BY DATE PERMIT'NO. INFO :R EH13-24(REV.$)Kt1 1 l�il[t tZl? 40'3.;�13S` E H 14.2E