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h { APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONIdENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE. (209)468-3420 P O BOX 2009, STOCKTON, CA 95201. LV PERMIT EXPIRES 1 YEAR FROM DATE IS9PED (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 Co ty Ordinance No. 549 and 1862 and the J4iles and Regulations of San iJoaquin County Public Health Servi ea.tJ - lu 1-7 i Job Address City Lot Size/Acreage I Owner's Name Address �' Phone ' IIrrf Contractor Addres � �' License N Phone TYPE OF WELL/PUMP: �� NEW WELL.❑-;e WELL REPLACEMENT L1 DESTRUCTION ❑ out of Service Well ❑ PUMP INSTALLATION ❑ ;a 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 rTIYPE OF WELL rPROBLEM AREA CONSTRUCTION SPECIFICATIONS L-1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Privfate L3 Gravel Pack ❑ Tracy Type of Casing Specifications {'1 Public Cl Other Ll Delta Depth of Grout Seal Type of Grout ! I Irrigation A A.Approx. De th 3 Eastern Surface Seal Installed by Repair Work Done Type of Pump H.P. _ State Work Done " Well Destruction` ❑ Wall Diameter Sealing Material & Depth Depth i- � Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALIATIONA.I. REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet.I Installation will serve: Residence_ Commercial Other Number of living units: it Number of bedrooms r Character of soil to a depthf 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 LEACHING LINE # ❑� fVo. &Jte I h a(s�nt s` ' - Total length/sire FILTER v_ _0 Dist R Bance to nearest:. Well Foundation Property Line SEEPAGE PITS I I Depth --Size Number BLIMPS Ll Distance to nearest: kWell' 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 I 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 comp sa- tion laws of California." The appli m t Call for all-req 're pectin Campl drawing on rse side. Signed II Title Date: I� FQB DEPARTMENT USE ONLY Application Accepted by �? Date �Z �_ __ Area { Pit or Grout Inspection by IM Date Final Inspection by Date f 2 g0 Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Eavironmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEEDFJE AMOUNT REMITTED CK N RECEIVED BY DATE PERMIT AMOUNT 0. INFO CASH �'] . EH 13-24MEV.rin51 jt f t t0- .kms _ EH y4-2lf rV4 tt`-i1 V r.