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\v 7APPLICAT'ION FOR PERMIT ..� f I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1641 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT_ EXPIRES 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 San Joaquin County Ordinance No. 549 and 1862�and -the Rules and Regulations of San Joaquin County Public Health Services. Job Address 04 City Lot Size/Acreage y., � � Owner's Narrle i <t1e Address Phone Contractor ` Addressicense No. O VYphone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT f_l DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 'E I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Well. Casing [I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'I Public 1-1 Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx.,Depth I t Eastern Surface Seal Installed by Repair Work Done-0 --p-Type..of-Pump - -- H:P.7-=- ._ State Work-Done Well Desnjrction ❑ Well Diameter' Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION"bi;�DESTRUCTION I I INo septic system permitted if public sewer is t available within 200 feet.) Installation will serve: Residence X1. Commercial Other Number-of living units:- L Number of bedrooms= t Character of�soil-to a depth of.3 feet: Water table depth s SEPTIC:TANK ❑ Type/Mfg i Capacity No. Compartments } PKG. TREATNIENTfPLT.❑ L Method of Disp6sal Distance to nearest: Well .Foundation, Property Line LEACHING LINE 4�r—No;& Length of lines J—_ t "Total.length/siza FILTER BED .❑ dis�ance tokiiearest. Well Foundation' s Property Lila Tr ,l SEEPAGE PITS IDepth A M '� $i:e i l l Number Il SUMPS LI Distance to nearest: Well, r I Foundation Property Line ” DISPOSAL PONDS ❑ 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-ln thii 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: ;'!certify that in the.'performance of the work for which this permit is issued,.1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for �A!Lteavire in ctions'.:Complete drawing on reverse side. -- r Signed Xt Ile Tide-` `��, � ? e,! y oars: � D t 'EPA_ RTMENT USE ONLY Application Accepted by Area �t J Date - 1ry Pii r Grout Inspection by ` Data .Final,l nspection by Date - Additional Comments: Applicant - Return all copies to: `San Joaquin-County Public Health i Services, Environmental Health"Permit/Services.— "f x 16017E. Hazelton'Ave., P 0 Box 2009, Stockton, CA 95201 FEE MOUNT DUE AMOUNT REMITTED CA H RCDATE PERM17'NO. INF . EH 1�2�IREV.�insi —, EK 14.2E 170 — i