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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 BOR 2009, STOCKTON, CA 95201 EXPIRES 1 YEAR FROM DATE ISSUM (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 1$62 and the Rules and Regulations of San Joaquin County/Public Health Servic f-o I f Y X111 �. Cit e I Lot Size/Acreage _ Jab Address /� Y F p 2011 E ��IVLQ � fes" v-�r Phone Owner's Address ■ los Contract � Address r �+��[�� License No._3z�'_Z _'Phone TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION L7 Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well [3 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL w OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS - e n Industrial C1 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 11 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications V1 Public C1 Other n Delta Depth of Grout Seal Type of Grout I I Irfigadon —.ApproK. Depth f 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 6 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAI I DDITIONK DESTRUCTION ( I (No septic system permitted if public sewer is b r available within 200 feet.l Installation will serve: Residence Commercial K Other Number of living units: Number of qdrooms t Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg l Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total iength/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ><Depth Size --�0 Dumber SUMPS LI Distance to nearest: Well Foundation _ Property Line. M— 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 u_ s It for a1 req '"spe!ctions.- ete drawing on reverse sfdV,U Signed X Title: ..Date: FOR DEP RTMENT USE ONLY .. Application Accepted by Da4e Area—/ 2 Pi r Grout inspection bye Date incl Inspection by ate--, Q Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services T 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED ASH CK RECEIVED BY DATE PERMIT N0. . EH 13-24(REV.tin51 EH __72 it-26 /