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In APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 4 ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 20091 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 Service )(Job (Job Address � City Lot Size/Acreage ZI "X Owner's Name r ddress 7 ,7/� /y" Phone Contractor ress License No. Phone TYPE OF WELL/PUMP• NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing [I Domestic/Private 0.Gravel Pack ❑ Tracy Type of Casing Specifications Il Public f:1 Other n Delta Depth of Grout Seal Type of Grout I 1 Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U . Type of Pump H.P. State Work Done_ Well Destruction O Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF,SEPTI ORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Res' e— Commercial Other Number of living units: Num f bedrooms Character of soil to a depth of 3 feet: table depth SEPTIC TANK.. ❑ Type/Mfg Capacity _ No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Fo n Property Line LEACHING LINE Cl No. & Length of lines tal length/size FILTER BED ❑ Distance to near Well Foundation operty Line SEEPAGE PITS 1 I th Size Number SUMPS Distance to nearest: Well Foundation Property Line DISPOSAL PO ❑ I hereby cert'y that I have prepared this application and that the work will be done in accordance with San Joaquin county ordin—iAtes, 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 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 m st call for all re u' d inspections. Complete drawing on rever side. V Signed X Title: _ 5 Date: lxo { OR PARTMENT USE ONLY Application Accepted by &.✓� %4A. �4nivv Date. Pit or Grout Inspection by Dates ` Final Inspection by Date Additional Comments: 3� �9Z 'Wi/i 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 CK 0 INFO AMOUNTDUE AMOUNT REMITTED CASH RECEIVED REECCEIVVEED/B�Y DATE PERMIT'NO. . EH 13.2!IREV.'i x 51�/1N g W _1. \ 1 i EH 71.26 Y� ii�l