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APPLICATION FOR PERMIT i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE � ^ ENVIRONMENTAL HEALTH DIVISION �u7 1601 E. HAZELTON AVE, , PHONE (209)468-3 20 P O BOA 2009, STOCKTON, CA 95201 I PERMIT EXPIRES 1 YEAR FROM DAZE 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. 5h9 and 1862 and the Rules and Regulations of San Joaquin County Public //Health Services. /} +� Job Address / 1 SC�� AWSEfZ City .1—/oZL Lot Size/Acreage Owner's Name / rm � /(� Address Phone �/J, ��f ��7s17� /lL'i iC Phone �� Contractor 'rte Address _ License No. TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service We11 D 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 —"f_]_Industrial - ❑ Open Bottom L] Manteca Dia- of Well Excavation Dia. of Well Casing 11 Domestic/Private ❑ Gravel Pack L] Tracy Type of Casing Specifications I'1 Public El Other Cl Delta Depth of Grout Seal Y Type of Grout ! I Irrigation _Approx. Depth i I Eastern Surface Seal instalied b� y Repair Work Done U Type of Pump H.P. t State Work Done_ Well Destruction ❑ Well Diameter Sealing Material &.Depth Depth Filler Materiel 6 Depth` >: TYPE OF SEPTIC WORK; NEW INSTALLATION I. REPAIRlADDITION V.'9 f DESTRUCTION i I (No septic system permitted it public sewer is v I' i avaiiable within 200-feet.) Installation will serve: Residence Zcommercial_ ther V, Number of living units: Number of bedrooms "t f Character of soil to a depth 3 feet- "'�' �''� Water table depth r SEPTIC TANK depth �— Ca acit -.,r/� p y No. Compartments i Method of Disposal PKG. TREATMENT PLT.❑ 11 j I , i Distance to nearest: Well 100 Foundation Property Line LEACHING LINE No. & Length of lines rt'�f ri�5 Total length/size Z t FILTER BED 0 Distance to nearest: Well Foundation Property Line r 1 SEEPAGE PITS Depth size Number ~ c^ i SUMPS LI Distance to nearest: Well Foundation�•7 - Property Line DISPOSAL PONDS ❑ r ! hereby certify that I have prepared this application and that the.work_wjil 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 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 yE 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 applican or all require ctions. Com to drawing on reverse side. i € Signed X- Title:..: '(,p _ Date: ,.. FOR DEPARTMENT USE ONLY Application Accepted by Date 1Z5 FO Area I: Pit or Grout Inspection by Date Final Inspection by 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 FES INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO, a EH 13-24(AEV.I/115) EH 114.26 r i