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APPLICATION FOR PERMIT SAN JOAQ UIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOR 2009, STOCKTON, CA 95201 PERMIT 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 No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Servic s. Job Address L7 of City Lot Size/Acreage l / !� L '2 Owner's Name Address Phone c r / 01 S License No Phone J Contractor Address n TYPE OF WELL/PUMP: f NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DI OS FLD. PROP. LINE FOUNDATION AGRICULTURE WELL THER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCT19KSPECIFICATIONS Cl Industrial ❑ Open Bottom ❑ Manteca Dia, of Wel avation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type;?f- I f asin Specifications I'l Public 1"--1 Other n Delta Dept Gr t Seal Type of Grout I Irrigation �.Approx. Depth I I Eastern Suace ea Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADOITIO 1l I D TRUCTION INo eptic system permitted if public sewer is va' ble 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. ❑ 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 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby cartify 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 subcontracting 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 call for all fired inspectio . Complete drawing on,reverse sidee. y � Signed X itle: ( irh� �' �� t� Date: L___=�/�'� FORD RTMENT USE ONLY Application Accepted by OA te Area 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO, + EH 13-24(REV.1/es! Y-2-7—LalyuEH A-2 A-2111