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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES (� ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 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 Services. ,-,_,, `,, �I- Job Address 11"S Z, &:, r''� '�' `� `�"�� City bi-az . Lot Size/Acreage Owner's Nam r Address . / _" "'�"t ` Phone `�-s �qo) Contractor Address A261, License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 9 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 n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing )C Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Il Public (-1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _.Approx. Depth� /( I Eastern Surface Seal Installed by Repair Work Done L7 Type of Pump �d�w H . 2 State Work Done Well Destruction ❑ Well Diameter Sealing.Material & Depth &4d gar -am—,_Z, Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ( I DESTRUCTION I I (No septic system permitted it public sewer is 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 SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl 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 O 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 oricensed 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 per n 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 must call for all required inspections. Complete drawing on reverse side. ,�� /� ^ Signed X t.Z__ 2X3a.R rdL,-- Title: t 1 Date:PITl R DEPARTMENT USE ONLY Application Accepted by Date A �DArea Pit or Grout Inspection by Date Final Inspection b Dawe✓4 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 AMOUNT DUE AMOUNT REMITTEDRECEIVED BY DATE PERMIT•NO. INFO C H [ . EH 17�-2s 3-21(REV.1/"s) EH Z S �jl /C,� o � , c0�� -7