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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)48$-3420 P O BOX 2009, STOCKTON, CA 95201 EXP RES 1 YEAR FROM DAT (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 1662 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address City Lot Si /Acreage r �}� Owner's Name Address Phone v ] Contractor � �nse No&-L�&Phone TYPE OF WEL / MP: NEW WELL WELL REPLACEMENT LJDESTRUCTION C1 Out of Service well CI i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I LADED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS .-- - n Industria ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wel asing n Ll Domestic/Privat ❑ Gravel Pack ❑ Tracy Type of Casing Specif tions V1�J I'I Public _ Other n Delta Depth of Grout Seal_ N f T e of Grout I # Irrigation rox. Depth I I Eastern Surface Seal Installed by Repair Work Done 13 Type of Pu H.P. State Work D _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material Zt Depth I TYPE OF SEPTIC WORK: NEW INSTALLATION l I EPAIR/ADDITION I I DESTRUC N INo septic system permitted it public sewer is available within 200 teet.l Installation will serve: Residence_ Commercial_` ther Number of living units: Number of bedrooms t Character of soil to a depth of 3 feet: -mow 1 Water table depth SEPTIC TANK. ❑ Type/Mfgr Capacity No. Compartments PKG, TREATMENT PLT.❑ E Method of Disposal Distance to nearest' Well Foundation Property Line i LEACHING LINE Cl No. & L th of lines { J Total th/size FILTER BED ❑ Dist nce to nearest: Weil Foundation Prop Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation . Property Line t DI5P05 PONDS Co I here certify that I have prepared this application and that the work will be done in accordance with San Joaquin county rdinances, state laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature cenifies the following: "I certify that in the performance of the work for which this p rmit is issued, I shall not 'I 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 st or u' Lins",ction,. Complete rowing On reverse side. Signed X' Title: Date: 4 yl 77 / I F DEPARTMENT USE ONLY J Application Accepted by Data h r Area evar 4 Pit or Grout Inspection by Date Final Inspection by Date ' i 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 AMOUNT DUE AMOUNT REMITTED CK RECEIVED 13Y DATE PERMIT NO. II INFO CASH g F a EH 13-24(rtEV.1/N 5) EH t4•2B 11