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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 O BOX 2009, STOCKTON, CA 95201 PFRMIT IRES 1 YEAR FROM DATE ISSURP (Complete in Triplicate) Application is hereby made,to San Joaquin County for a permit to construct and/or install the *cork 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. r Job Address �O --7i City Lot Size/Acreage Owner's Name Address _ -_-- Phone Contractor Address ` License No. �� 0, TYPE OF WE NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well L7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1-1 Domestic/Private ❑ Gravel Pack Ll Tracy Type of Casing Specifications Fl Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L7 Type of Pump H.P. State Work Done_ Well Destruction D Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITIOpf 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 bed roa "s _ rv-- Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK El Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line Of LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Cl Distance to nearest: Well — Found ion t05:0 Property Line�� ! SEEPAGE PITS 11 Depth Size _ Number ,. SUMPS LI Distance to nearest: Well,/ Foundation Property Line DISPOSAL PONDS ❑ 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: "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 mu call to all requir ins tions. C plate drawing on reverse side. r Signed X Title: -_ Date: ` FOR DEPARTMENT USE ONLY Application Accepted by Date, Area �l Pit Grout Inspection by Dal Final Final Inspection by Dat, -3-91 Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health ` Services, Environmental Health Permit/Services r 1601 E. Hazelton Ave., P 0 Sox 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO, . EHt324IREV,1in5s f/`/ 10 1 /L_�- va 23ci /p// i_ EH 1 4-2e