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APPL I CATION ,v�R PERM I T SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-342W- P O BOX 2009, STOCKTON CA 95201 inn PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL- HEALTH (Complete in Triplicate) PERMIT/SERVICES 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 City Lot Size/Acreage Owner's Name `i Address Sc,VVI P Phone Contractor �� NfiletlfAddress ala S /DAQ License No. ! A 5�V Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT O DESTRUCTION O Out of Service Well PUMP INSTALLATION ❑ SYSTEM REPAIR` OTHER O Monitoring Well O 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 n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing )j Domestic/Private O Gravel Pack 0 Tracy Type of Casing Specifications l'I Public [_1 Other (l Delta Depth of Grout Seal Type of Grout I I Irrigation _.Approx. Depth eI I Eastern Surface Seal Installed by Repair Work Done Type of Pump H.H.P. 5— State Work Done Well Destruction O Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is (> available within 200 feet.) rf Installation will serve: Residence_ Commercial_ Other O© Number of living units: 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. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE CI No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line -� DISPOSAL PONDS O 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an 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 applica call for all required ' spectio Complete drawing on arsels'ide. /1 17/1 Signed XTitle: / e Date: FO PARTMENT USE ONLY Application Accepted by4Date "'((fi�d J Area Pit or Grout Inspection by Date Final Inspection by_s �X- �A Datai2=Z 7– b Additional Comments: 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PE09 RMIT'NO. + EH 13.21(REV.t/R5) EH A-26