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i APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 I } P O BOR 2009, STOCKTON, CA 95201 i EXPIRES 1 YEAR FRQM 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 s >O City Lot Size/Acreage 1/3 1�-C_ Owner's Name Address Phone 36el-F 1/'19 OPO Contractor Address License Phone`3a`$?�J9 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Nell ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well 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 Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 5 Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications) I'I Public r 1-1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation „__Approx. Depth I I Eastern Surface Seui installed by Repair Work Done. 0 Type of Pump H.P. State Work Done_ f Well Destruction O Well Diameter Sealing Material & Depth ; r Depth Filler Material & Depth. ' y F TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION 14DESTRUCTION I I,INo septic system permitted it public sewer is fi available within 200 feet.) (}� Installation will serve: Residence Commercial _ Other . .-Number of livings units: _L - Number of bedrooms Character of soil;to a depth of 3 feet: Water table depth SEPTIC TANK. Type/Mfg Capacityw No�Compartments PKG, TREATMENT PLT, ❑ "t• T r' Method,of Disposal Distance to nearest: Well'20 Foundaiion Property Line #_ LEACHING LINE L'_No. & Length of lines .0 $ Y Total lengthlsize\ r f FILTER BED { C] - Disiance to nearest; Well �s Foundation �Q I1Pro- Line ._, SEEPAGE PITS I<Depth Number SUMPS ' Cl Distance to nearest: Well 42 r Foundation Property Line `f DISPOSAL PONDS ❑ -�-+ -- ~ �' _ r 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 folio wing: "I certifythat 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 signatur 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 compens tion laws of California." The app nt ust�catl for al! equ-red inspections. Complete drawing on reverse side. ,rSigney tTiNe: t' Date: t k s FOR DEPARTMENT USE ONLY pplicslion Accepted by Date� � Pi or Grout Inspection bata , Final Inspection by ate .G Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health M' Services, Environmental Health Permit/Services 1601 E. Hazelton Ave.�PO-Hox 2009, Stockton, CA 952OI FEEAMOUNT DUE AM UNT REMITTED RECEIVED BY DATE PERMIT'N0. INFO EH13-24(REV.rinse !' f EH 91.20