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r 0 APPLICATION FOR PERMIT SAN J'OAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOA 2009, STOCKTON, CA 95201 If %P RBS 1 YEAR FROM 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 compliance with ,fan Joaqu •County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Sera es. :g Job Address 74/ City of Size/Acreage + Owner's Name r phone i AUContractor ddress ansa No. 2v hone TYPE OF WELL/POMP: NEW ELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR C7 OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F) Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r-1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public C] Other 1-1 Delta Depth of Grout Seal Type of Grout 1f i I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by �J Repair Work Done ❑ Type of Pump H.P. State Work Done Weil Destruction ❑ Well Diameter Sealing Material to Depth Depth '~ iTler l4tsterial Aepth TYPE OF SEPTIC WORK: NEW INSTALLATIO 1 1 4 PAIR/ADDITION DESTRUCTION I I INo se tics stem P Y permitted if public sewer is __ 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: cn� Water table depth ' SEPTIC TANK. ❑ Type/Mfg Capacity No..Compartrnents PKG. TREATMENT PLT. C7 Method of Disposal f Distance to nearest: Well Foundation Property Line LEACHING LINE L1 No. & Length of lines Total length/size r. FILTER BED ❑ Distance to nearest: Well Foundation Property Line r SEEPAGE PITS 11 Depth Size Number S LI Distance to nearest: Well y tan tion Property Line DISPOSAL PONDS El 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 u o all r ired i s ct ns. Complet rawing on reverse side. Signed Title: Dater OR DEPARTMENT USIE ONLY Application Accepted by Date — f Area Pit or Grout Inspection by Date Final Inspection by Date 1 3 Q Additional Comments: Applicant — Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave.. F 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT N0. r CK INFO + EHt3-N(REV.11R51 Jsr. ,� 3n 9 1 )_)w