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r � I APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSU-ED.- . , (Complete is Triplicate) Application is hereby made•to San Joaquin County for a permit to construct and/or install the work herein described. This I 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 +� i f ,'{�r y - City JESCtAfnf] Lot Size/Acreage Owner's Name y'T r fid'� irS ---. Address Phone { Contractor i—row -�" __ ll.�r- Address t License No, Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ED DESTRUCTION ❑ Out of Service 4fei1 0PUMP INSTALLATION C] 1�_SYSTEM REPAIR ❑ OTHER ❑—Monitoring Well "CJ t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE j FOUNDATION AGRICULTURE-WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS e i L1 Industrial ❑ Open Bottom ❑ Manteca Dia: of Well Excavation � �Dia.e of Well Casind 11 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f i'1 Public Cl Other [I Delta ` Depth of Grout Seat Type of Grout I, I Irrigation _.ApproK. Depth ( I Eastern Surface Seal Installed by _ Repair Work Done U Type of Pump H.P. .State Work Done _ • Well Destruction ❑ Well Diameter Sealing Material & Depth f i Depth Filler'Material b Depth s TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION Ar DESTRUCTION I l INo septic systempermitted it public sewer is t QM available within200 feet.) Installation will serve: Residence Commercial�.___. Other ' - Number of living units: --I—.. Number of bedrooms- Character edroomsCharacter of sail to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/MfgCapacity �•No. Compartments k PKG. TREATMENT PLT. ❑ ,�- ,_ .,#- Method of Disposal Distance to nearest: Well r Foundationt Property Line •,.f � p LEACHING LINE No:`$ Length of lines �� ' i Tofal length/size J i FILTER BED 0 Distance.to nearest: Well y Foundationt t.r Property Line �. _ SEEPAGE PITS 11 Depth Size l rte•-. .-fir Number 4 f rSUMPS Distance to nearest: Well Foundation!,,, Property Line _ DISPOSAL PONDS ❑ 4 r I 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: '9 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." _s The applicant must call for all required inspections. Complete drawing on reverse ide. t r t Signed Title: y G Date: FO E ONLY _�. �».•� �--�t Application Accepted by _ Date Arpa If Pit or Grout Inspection by Date Final Inspection b Date ! Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services t 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, •CA 95201FEE i INFO AMOUNT DUE, AMOUNT REMITTED ,�CASH K i RECEIVED BY- DATE__" fPERMIT'NO�.EH 13.24IREV.ItA5) 1 Q A AEH 1425 ��/\