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APPLICATION FOR PERMIT �1 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION f•Cv 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 P%M11 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 Ho. 549 and 1862 and the Rules and Regulations of San � Joaquin County Public Health Services. _ /� Job Address __ 3_ L/ J[ l / City Lot Size/Acreage / � Owner's Name Phone Contractora__=Z_r.JAress A 44 cense No.0� Phone TYPE OF WELL/ U P: _ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Out of Service well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ti3 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL- PROBLEMAREA-� CONSTRUCTION SPECIFICATIONS E Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing Ca Domestic/Private ❑ Gravel Pack, `• ❑ Tracy, Type of Casing Specifications j I'I Public 17 Other n Delta Depth of Grout Seal Type of Grout t I ifrigation _Approx. Depth I 1 Eastern Surface Seal Installed by r Repair Work Done U Type of Pump H.P. State Work Done i Well Destruction ❑ Well Diameter Sealing Material Depth Depth Filler Material & Depth � TYPE OF SEPTIC WORK: "NEW INSTALLATION IV REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is + �`- "i _ �y L available within.200_feet:) - - �- Installation will serve: Residence_ Commercialf�" Other .Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: v,- Water table depth SEPTIC TANK 0 Type/Mfg Capacity 4Q 0 No. Compartments PKG. TREATMENT PLT. ❑ IF Method of Disposal Distance to nearest: Well,.Z__:�Foundation Property Line i LEACHING LINE ❑ No. & Length of lines 1 Total length/size FILTER BED ❑ Distance to nearest: Well442�_-4oundation F__V Property Line _ SEEPAGE PITS 11 Depth Size c Number SUMPS Ll Distance to nearest: Well t4v_�Foundation �n_ Property Line F DISPOSAL PONDS ❑ L '� 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 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 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 #o II reqwimd inspections. Complete drawing on reverse side. Signed X A, Title: L4 qd% _ Date: GLJ FOR DEPARTMENT USE ONLY I _ � I Application Accepted by Date-./. Area �/ # �i or Grout Inspection by ate��/[ Final Inspection by ,�._., Date Comments: 2`Additional ( - 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 INFO AMOU�NT/DUE AMOUNT REMITTED ASH CK RECEIVED BY DATE PERMIT'NO. + EHft4�2e 3'-24 IREV. EH 1/h51 `.�