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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 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 �� .� City �� g.e Lot Size/Acreage Owner's Name Address �+ � � Phone Contractor Address ALicense No.y�t^LVIL—Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ _M- °ring Well [3 DISTANCE TO NEAREST: SEPTIC TANK SEWER-LINES -. DISPOSAL PROP. LINE FOUNDATION AGRICULTURE WELL WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM.AREA CO TION SPECIFICATIONS El Industrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation Dia. of Well Casing 1-1 Domestic/Private ❑ Gravel Pack 0 Type of Casing Specifications ('1 Public fl Other (l Delta Depth of Grout Seal Type of Grout I I Irrigation �.NPWIrDepth I I Eastern Surface Seal Installed by Repair Work Done U e of Pump H.P. State Work Done_ Well Destruction Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 1 1 DESTRUCTIO IMo septic system permitted it public sewer is \ ;�/ available within 200 feet.) � y1\\\\ Installation will serve: Res' �\ Commercial_ Other Number of living units: umber of bedrooms Character of soil to a depth—.1 3 feet: Water table depth `\ SEPTIC TANK ❑ Type/Mfg Capacity J44or No. Compartments 2 PKG. TREATMENT PLT. ❑ Method of Disposal ( � Distance to nearest: Well 4& Foundation /0 S Property Line D LEACHING LINE No.-& Length oflines' �^�� Total length/size � FILTER BED ❑ Distance to nearest: Well T'^ Foundation -2-6 Property Line /,0 SEEPAGE PITS 11 Depth Size Number V SUMPS LI Distance to nearest: Well Foundation Property Line 1` 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-foNowing: "t 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 applicant t call for all rwWired i spections. Complete drawing on reverse si e. G� Signed X Title: Date: PARTM_ ENT USE ONLY C� Q Application Accepted by Date `� Area I t 1 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant Return all copiest oaqu n y c H alth bdowt QkS_MO &0 Services, Environmental Health Permit/Services r JM� ox (,VA&cs:o 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PEyRMIT'N(0�. + EH 13.2 (REV.r i x 51 a®� / rc J`_/Io Ifo /�J EH 14-2111 !� /rp