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a5 APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION E 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 Now 4 t}� i I SNIT EXPIRES 1 YEAR FROM DATE- ISSUED N� Q•�� (Complete in Triplicate) Alf- - 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 Ho. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Heallth Services. i L lse T City � Lot Size/Acreage Job Address 46 �J Owner's Name G IN Address r �5� - Phone -r Contractor _: Address License No. Phone TYPE OF WELL/PUMP: I NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well Cl PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ 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 n Industrial ❑ Open Bottom" ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Ll Domestic/Private ❑,Gravel Pack L1 Tracy Type of Casing Specifications F1 Public r ther 1`7 Delta Depth of Grout Seal Type of Grout I I Irrigation .Approx. Depth 1 ) Eastern Surface Seal Installed by Repair Work Done L7 Type of Pump ; H,P. State Work Done t , Sealing Material & Depth Well Destruction ❑ Well Diameter I Depth Piller Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION ! I REPAIR/ADDITION i I DESTRUCTION INo septic system permitted if public sewer is III available within 200 feet.) Installation will serve: Residence— Commercial— Othb Number of living units: Number of bedrooms Character of soil to a depthF of 3 feet: Water table depth r1 SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ y°+y Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS El Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ } 1 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 agsAfs signature cenifies 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 taws 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 Californis The applicant must all for all requi nspections. Complete drawing on reverse side. f � Signed Title: Date: FOR D ARTMENT USE ONLY Application Accepted by �'`� _ Date 5^A 1 Area Pit or Grout Inspection by II' Date Final Inspection bj' � �1::� Date i Additional Comments: IIS Applicant - Return all copies to: San Joaquin County Public Health \, j Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P x 2009, Stockton, CA 95201 I FEE MOUNT DUE AMOUNT REMITTED CH RECEIVED BY DATE RMIT NO. PE INFO :c ..i EH 17.24 IREV,rinyt ,� �D� 'UD �� S`21— I� �Q�� EH 162E t. 1N