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e ' APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVYSION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 � .PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 19 SZ A 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 1862 and the Rules and Regulations of San Joaquin ty Public Health Services. Joh Address V -�Z-�L City Lot Size/Acreage Owner's Name r�L��12��Address 91 y Phone i �Contractor Address License No. Phone YPE 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 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing P Domestic/Private ❑ Gravel Pack n Tracy Type of Casing 1 Specifications I"i Public Cl Other n Delta Depth of Grout Seal Type of Grout I I Irrigation + —,Approx. Depth I I Eastern Surface Seal Installed by Repair Work pone LJ Type of Pump H.P. f State Work Done _ Well Destruction ❑ Well Diameter Sealing'Material & Depth Depth Filler Material & De t TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I IDE STAUCTIO I [No septic system permitted if public sewer is available within 200 feet.I Installation will serve: Residence— Commerciale Other i' Number of living units: Number of bedrooms M 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 Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED 1-1 Distance to nearest. 1 Well Foundation Property Line r�a ry 1 SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation r Property line DISPOSAL PONDS 13 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, andv 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 7r call for all req uir inspections: Co-mpTta dPawi g on rev rse side, Signed X Title: I� Date: '] R DEP RTMENT USE ONLY Application Accepted by — Date Area Pit or Grout Inspection by / Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO H . 1 EM J-24 IREV.riHSY �n 7L/,v0 01 3-2e F