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APPLICATION FOR PERMIT " SAN 30AQUIN CO[ JNTY PUBLIC"HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION " 1601 E. HAZELTON AVE. , PHONE (209)468--3420 P O BOX 2009, STOCKTON, CA 95201 EXPIRES 1 YEAR FROM DATE IS9UID (Complete in Triplicate) Application is her 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. City Lot Size/Acreage Job Address _ Address Owner's Name l Phone Contractor Address License No. Phan 3 TYPE Of WELL/PUMP: NEW WELL E=1 WELL REPLACEMENT C_l DESTRUCTION L] out of Service Well L� PUMP INSTALLATION D SYSTEM REPAIR C7 OTHER O Monitoring Well -L7 DISTANCE TO NEAREST:`SEPTIC TANK'' —` SEWER-LINES` —"DISPOSAL FL'D:�""'""""PROP""L"INE"' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ' INTENDED USE AYPE OF WELL PROBLEM AREAS CONSTRUCTION SPECIFICATIONS f_7 Industrial �.,.��❑ Operi Bottom Q Manteca Dia. of Well Excavation Dia. of,Well Casing I! Trac Type of Casing Specifications C:1 Domestic/Private ❑ Gravel Pack..,._...._....- Y� � TYPe of Grout H Public 1-1 Other ! n Delta Depth of Grout Seal"" I I Irrigation Approx..Depth I l Eastern Surface Seat Installed by tal Pump ' f H P State Work Done _ Repair Work Done L7 Type Sealing Material b Depth Well Destruction O Well Diameter' "- v . Filler Material 8 Depth Depth TYPE OF SEPTIC WORK; NEW INSTALLATION 1)i( REPAIWADDITION 14 DESTRUCTION I 1 iNo septic system permitted it public sewer is `»-available within 200 feet.) In stallationwill serve: Residence_e Commercial_ Other Number of living units: _ Number of bedroomCQ Character of soil to a depth of 3 feet: / � Water table depth SEPTIC TANK ❑ Type/Mfg Capacity y[as _ No. Compartments PKG. TREATMENT PLT. Cl Method of Disposal Distance to'nearest: Well� Foundation ��'�`� Property Line _ _ t 4Totallength/size =7 ".� LEACHING LINE—== ❑°^ Not -Length of lines _ 4 �>��F Foundation �s~F Property Line f FILTER BED O Distance to nearest: Well-;l-G. A" � Number SEEPAGE PITS ~'I l 2Depth l �� size SUMPS r'tLl Distance to nearest: Well��7_Foundatior _ �s�' Property Line DISPOSAL+PONDS } -. ❑'r �'' ��-"---'^'`.Y, "`P"�{ f 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 M - r i 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, k shall not employ any person in such manner be r as to. come subject to workman's compensation laws of California." Contractor's hiring or sub contracting signature certifies the following: "I certify that.in the performence'of the work for which this permit is issued, I shall employ persons subject to workman's compensa tion laws of California." :}Q� � r aH squired inspections. Complete drawing on reverse side. (The applicant must call fo Signed �' Title: _ Date: '� RT -ONLY Application Accepted by"`"' Date r A Pit or Grout Inspection by Date Final inspection b M1 s Additional Comments: - ,+_ Applicant =Ie'turn ell'copise to• Ssm Joaquin,Countg Public Health -- *--^�° w—Servides,� Ftivi.ronmen'£al'Tiealth Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 l FEE AMOUNT DUE AMOUNT REMITTED CASH CK I RECEIVED BY DATE PERMIT'NO. INFO /�/�]�J DAF 9 �9 « EH 53-24{DEV-1 N 51 r 0-0 Ll . a� % 4 r EH 14.20 ll