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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 1 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 /P�uubblic Health Services. Job Address /T� / ~ &C City.0211 Lot Size/Acreage Owner's Name Address Phone Contractor Com_Address m License No. �©S S'PhJ6'�' � TYPE OF WELL/PUMP: NEW WELL ❑ WELL REP ACEMENT ❑ DESTRUCTIQN' Out of Service Well O PUMP INSTALLATION O SYSTEM REPAIR O OTHER O 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 F) Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack O Tracy Type of Casing Specifications I'I Public fl Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth 'r TYPE OF SEPTIC WORK: NEW INST REPAIR/ADDITIO Wf DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence 4 Commercial_ Other I Number of living units: ___I4 Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, O _ Method of Disposal Distance.to nearest: Well X57 Foundation Property Line_ LEACHING LINE Cl No. & Length of lines � Total length/size FILTER BED ❑ Distance to nearest: Well Foundation O Property Lines SEEPAGE PITS 11 Depth ,�� Size _ 40 -- _ Number SUMPS LI Distance to nearest: Well MQ_'Foundation r Property Line lC� 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 in the,performance of the work for hich this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." ContraEtor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, l shall emplaypersons subject to workman's compensa- tion laws of California." The applicant must r all required in tions. mplete drawing on reverse side. Signe Title: -_ �` Date: `57��o DEPARTMENT USE ONLY Q lication Accepted by Date 5 4—�l� Area Pit Grout Inspection by�—=� Dates _��" �'�-tinal Inspection by � ��n�� Data- dd'tional Comments: C - n L Applicant — Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 INFEMOUNT DUE AMOUNT REMITTED ASN RECEIVED BY DATE PERMI7'N0. + EH 13.24(REV.I/A 5) EH 4-26