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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 .URMIT EXPIRES 1„YEAR FROM DALE 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. Job Address _.._ F_ .,,2e— City Lot Size/Acreage =2e-114� Owner's Name Address 7Phone Contractor „ Address License No.&0s;W 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 171 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing F Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications i'I Public 1-7 Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation _..Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ 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/ADDITION t70ESTRUCTION I 1 INo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: 4,_ Number of bedrooms f Character of sail 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 �9 LEACHING SINE 0—No. & Length of lines C7. Total length/size FILTER BED ❑ Distance to nearest, Well Foundation 3 40 Property Line G r k SEEPAGE PITS i''I—Depth a r Size ey Number SUMPS LI Distance to nearest:, Well�. Foundation_ Property Line IT� DISPOSAL PONDS ❑ t 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 4 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." 1 The applicanwnust Call for all requir ins ctions. Complete drawing on reverse side. \. ,f, j Signed r Titfe: �+ Date: FOR DEPARTMENT USE ONLY Application Accepted by ^ Date 4 ?_ 9j L Area - � it or Grout Inspection by Date`� Final Inspection by_T 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 UNT REMITTED AMOUNT OUE AM CASH RECEIVED BY DATE PERM17'N0. + EH t3_244REV.t/A5) �'/¢�I{t O�� ZC1¢� EH 14.26 (8/ V 5'�7 0 L 1