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R APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXP RES 1 YEAR FROM DATE ISaUM (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 City Lot Size/Acreage Owner's Nam Address 1 Phone 2 Contractor Address License No Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT77 DESTRUCTION ❑ Out of service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE s FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PR08LEM AREA CONSTRUCTION SPECIFICATIONS = n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing C'7 Domestic/Private ❑ Gravel Pack El Tracy Type of Casing Specifications FI Public t 1-7.0ther I A Delta Depth of Grout Seal Type of Grout i I Irrigation _..Approx.,Depth l I Eastern Surface Seal Installed by � Repair Work Done 0 Type of Pump H,P. State Work Done Welt Destruction ❑ Well Diameter Sealing Material & Depth F Depth Filler Mate'r`ial & Depth I TYPE OF SEPTIC WORK: NEW INSTALLATION——REPAIR/ADDITION I f DESTRUCTION I I INo septic system permitted if public sewer is 3 0% 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: j t Water table depth SEPTIC TANK- ❑ Type/Mfg I NCa acity _ . Compartments J PKG. TREATMENT PLT. ❑ -` Method of Disposal ' Distance to nearest: Wello— Foundation Property Line ±1_17 LEACHING LINE K No. & Length of lines ��- 9 Total length/size 46::' r FILTER BED t n Distance tori nearest: Well J1_ s�r Foundation 69LI - Property Line 111 S A--7— I SEEPAGE PITS 11 Depth O 'Siie e Number SUMPS Distance_to nearest: Well_flF/ Foundation DISPOSAL PONDS -�- � Property Line I hereby certify that'l have prepared this application and that the work will be.done in accaidance with San Joaquin county ordinances, state laws, and i rules and regulations of the San Joaquin County Home owner or licensed agent's signature,certifies the following: _I.csrtify.that in.the performance of-the work for which this permitisissued, I shall not employ any person in such manner as to become subject..to workman's compensation laws of California." Contractors 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." f - j l The applicant must call for eq ins pec i s. Complete drawing on reverse side. r Signed F Title: Date: l { OR ARTMENT.USE ONLY Application Accepted by Date Pit or Grout Inspection by Date ~ Final Inspection by-a-QCI-., ._ rqy -r Date Additional Comments: Applicant - Return all copies to: i8a.n Joaquin County Public Health f Services, Environmental Health Permit/Services I 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 i i..r w 'FEE INFO AMOUNT DUE AMOUNT REMITTED-- 7-t A' +r RECEIVED'EY"" -"- CASFI i DATE`� ` `PEFtM1T ►JO. . EH 13-24 lt1EV.1 i H sr I ©� ' . "'- EH 94.ZtS 1 /D—tom Q 1