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APPLICATION FOR PERMIT 10 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ' ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$3420 r`*`= P O BOX 2009, STOCKTON, CA 95201 PF"IT EXPIRES 3 YEAR FROM DATE IgEtUM (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 Lot Size/Acreage Owner's Name Address i i Contractor r Address License No3� 2 L Z -hone TYPE OF WELL/PUMP: V NEW WELL C1WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 11 Monitoring Well ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ° D Industrial [JOpen Bottom ❑ Manteca Dia- of Welt Excavation Dia. of Well Casing - [I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1'I Public t-1 Other (l Delta Depth of Grout Seal TypeofGrout I I Irrigation _App(ox. depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done Q Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material A Depth f TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION DESTRUCTION I I INo septic system permitted if public sewer is 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. ❑ Type/Mfg Capacity- No. Compartments - PKG. TREATMENT PLT..❑ �:`�.; 4 J� 4 -s y --Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No& Length of lines: Total length/size' FILTER BED CI Distance to nearest.: Well -^ Foundation Property Line 14'' t S3 SEEPAGE PITS 11 Depth �Size r Number SUMPS Distance to nearest: Well Foundation. _ Property Line --- DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be'doain accordance with-San�JoaquinLCounty ordinances, state laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following:."I certify that iri-the performance of the work,for this.permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of Calif ornia."Xcintrac•tor's-hirin`g.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 must Callof all r u ed "..tions. Complete drawing on reverse Signed X Title: Data FOR DEPARTMENT USE ONLY Appli tion Accepted b / Date ��/ Area rou nspection by Date (Final Inspection bye — Date 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 aFEE [ AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMITN0. CASH i4 r EH 13-24 IREv.I I n 5 CQJa fyf EH 1446