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i f APPLICATION FOR PERMIT" SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZHLTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 i PERMIX EXPIRES 1 YEAR FROM DATE ISSURD (Complete iu 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. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. Jab Address City Lot Size/Acreage _ Q i i "Qwner's-Nam t Address &u Phone nZZ� Phone 6" " e�s Contract Address /� License No. TYPE-OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 5, INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS a ' Cl Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack 0.Tracy Type of Casing Specifications ` F1 Public Ia Other 171 Delta Depth of Grout Seal Type of-Grout - 1 I Irrigation ___..Approx. Depth I I Eastern Surface Seal Installed bg Repair Work Done 0 Type of Pump ',H.P._. .. 1 . State Work Done T Well Destruction- --"❑ --Well Diameter _Sealing Material & Depth Depth 1ler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPA /ADDITION DESTRUCTION I i INo septic system permitted if public sewer is 'x .x -available within 200 feet.! Installation will serve: Residence r Commercial'.. Other �. Number of living units: _L_ Number of edrooms Character of soil to a depth of 3 feet: _._Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest-Well's foundation ` Property Line LEACHING LINE 0 No. & Length of lines �` Tofillength/size p FILTER BED C] Distance to nearest: Well Foundation �� Property Line SEEPAGE PITS 11 Depth _. Size X Number l SUMPS Distance to nearest: Well U'_ Foundation Alf Property Line. t DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the.work will be dans in accordance with San Joaquin county ordinances, state laws,Ud 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 workmt3n's corttpensatibn_laws_of:Califorriia."Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this,permit is 46_64d, I shall employ persons subject to workman's compensa- tion laws of California." = -ri" t The applicant m call foreq fired inspections. Complete drawing on reverse de. Signed X Title: [ Date: 6 / FOR DEPARTMENT USE ONLY Application Accepted by Y'` -- —.— _ Date S"'�5 —Sc1 Area Zf� Pit or Grout Inspection by Date Final Inspection by� Additional Comments: Applicant - Return all copies to: Sen Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEECK T P RMIT'N . INFO CASH AMOUNT DUE AMOUNT REMITTED RECEIVED BY DA E E O r EH 13-24(REV.t/R 51 EH 74-26 C7 l l