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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES . ENVIRONMENTAL HEALTH DIVISION \, 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 i- 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. / JobAddress Q/ Cit /Lot Size/Acreage AC ,� ra . Phone Owner's Name it1�'1P Address �//� /�_ CS7 Contractor A72 —7--?, Address P4 �O k L9 2 7 icense No.&Z 373 Phone TYPE OF WELL/PUMP: IIEW WELL O WELL REPLACEMENT DESTRUCTION crbut of Service Well O PUMP INSTALLATION 4--" SYSTEM REPAIfi ❑ OTHE5 O Monitoring Well 0 DISTANCE TO NEAREST: SEPTIC TANK -� SEWER LINES ZJ= , DISPOSAL FLD.JA PROP. LINE _�O 4- ' FOUNDATION � AGRICULTURE WELL OTHER WELL 3JQ, PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C_l I`ndustrial ❑� Open Bottom ❑ Manteca Dia. of Well Excavation vc Dia. of Well Casing CR0oomestic/Private &- ravel Pack El Tracy Type of Casing Specifications i1 Public 1'.1 Other rl Delta Depth of Grout Seal —1 pe of Grout I I Irrigation _.Approx. Dept I I/Eastern Surface Seal Installed by C� Repair Work Done M Type of Pump H.P. State Work Done Well Destruction Q-Well Diameter _ Sealing Jdptserial & Depth Depth Filler–Wts elkal & Depth TYPE OF SEPTIC WORK: NEW INSTALLAT40N 1-1.-...REPAIR/ADDI1`ION 1 1 DESTRUCTION I I (No septic system permitted if public sewer is available witNn 200 feet.) " Installation will serve: Residence_ Commercial_ Other ,F Number of living units: Number of bedrooms f' Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK, 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method-6f Disposal Distance to nearest: Well Foundation Property Line 'r ,LEA,cHfNG_LINE. O No. & Length of lines Total length/size FILTER BED ❑ Distance to neatest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line., -DtSPOSAL PONDS O + 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 sigrtlature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employany per manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the owing:"I c i that in t or a of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws California." The appli ant mu f OR r plate drawing o �., `�ti:� Signed XTitle: " wy Date: FO EPARTMENT USE ONLY Application Accepted by &�, Date Area Pit or Grout Inspection b Date Final Inspection by bats Oil Additional Comments: Applicant – Return LJA copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMITeNO. + EH13.211REV.1in5l 2 EH 11.2e J