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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES5 r ENVIRONMENTAL HEALTH DIVISION 1.601 E. HAZELTON AVE. , PHONE (209)46$-3420 �pVAP 0 BOR 2009, STOCKTON, CA 95201 IC4 PEMIT EXP RES 1 YEAR FROM DATE ISSUED NID (Complete in Triplicate)_` r Application is hereby made.to San Joaquin County for a permit to construct and/or install the work herein described. This 1 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 -e3 -Af-r- City Lot Size/Acreage s Owner's Name Addresses Phone e C ��g + Contractor Address r License N� 1_G` _ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WE L REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Ll OTHER ❑ Monitoring Well C7 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 n Industrial ❑ Open Bottom —. 9-Manteca-- "" Dia. of Well..Excavation - Dia. of Well Casing I f.l Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications I'l Public 1-1 Other n Delta De rout Seal Type of Grout I i Irrigation — Approx. Depth I I Eastern Su Pump rface Seal Installed by Repair Work Done ❑ Type of Pup H.P. State Work Done , Well Destruction ❑ Well Diameter Sealing Material & Depth Depth f" Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION 1 1 DESTRUCTION X(No septic system permitted if public sewer is (� 1 .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 C SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ E 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 fo-1lovving: "I"certify thai in the peri qce of the work for which this permit is issued, t 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 applican st call for all gpe.qiAs. Complete drawing on reverse side. Signed t Title: Date: O 5E ONLY I A - ation Accepted by 11 Date -- S. Area {{ Pit or Grout inspection by Date Final Inspection by % Date Additional Comments: Applicant _ Return all copies to: San Joaquin C61iaty Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 IEEE MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV.)/a51 EH t4-26