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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERV-I-CES ENVIRONMENTAL HEALTH DIVISION 6 am -E IV E mu" 1601 E. HAZELTON AVE. , PHONE (209)468-3ams P 0 BOX 2009, STOCKTON, --.CA-_95.201 nL C -PERMIT EXPIRES 1 YEAR FROM DATE_ LSSu� All C 13 1990 (Complete in Triplicate) ENVIRONMENTAL HEATH Application is hereby made to San Joaquin County for a permit to construct and/or install thREW Ui1SE d1"d. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County bli alth Service' ery ces. t o� A&��(e r so AJ S�- 11 Job Address City Lot Size/Acreage A�� . Owner's Name ddressEJL_ hone Contractor Address License N Phone_ — TYPE OF WELL/PUMP: f4EW WELL ❑ WELL REPLACEMENT i1 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Ll OTHER ❑ Monito> ng Well ,V� Iti7 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing (-1 Domestic/Private Ll Gravel Pack Ll Tracy Type of Casing /4 Specifications i'l Public is Other i7 Delta Depth of Grout Seal y� Type of Grout I I lrrigation — Approx. Depth I I Eastern Surface Seal installed by Repair Work Done LJ Type of Pump H.P, State Work Done_ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I 1 DESTRUCTION I I INo septic system permitted it public sewer is r available within 200 feet.) Installation will serve: Residence_ Commercial — Other , Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK D Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size i FILTER BED C1 Distance to nearest: Well Foundation - Property Line SEEPAGE PITS 11 Depth Size _ Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work wiN be done in accordance with San Joaquin county ordinances, state laws, and3 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, 1 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 r------ 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 must callfor a re d inspections. Complete drawing on revers side. - Signed X Title: _ Date. FO PAR SE ONLY Application Accepted by Date Are ` Pit or Grout Inspection by Date Final Inspection by Date -P-`T 746 Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/services f 1601 E. Hazelton Ave., F 0 Box 2009, Stockton, CA 95201 INFO AMOUNT DUE AMOUNT REMIT-TED CASH / RECEIVED By DATE PERMIT NO. + EH13-24(REV,I/H!5) V CS�(� I J t-�L �z EH i4 2e r ) /r