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APPLICATION fOR PERMIT nN SAN JOAQUIN COUNTY -PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 98201 EXP RES ] YEAR FROM DATE (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. City [ ' 737 � t Job Address Lot Sine/Acreage Owner's Name " vAddress Phone Contras tor¢ Address license No, TYPE OF-WELL/.f 5VP: NEW WELL ❑ WELL IKEPLACEMENT ❑ DESTRUCTION C] Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES A DISPOSAL FLD. PR'OP. LINE FOUNDATf0A4 AGRICULTURE WELL OTHER WELL PITS./SUMPS INTENDED USE TYPE,61F WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ; n 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 El Other n Deity Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth i I Eastern >_ Surf4ce Seal Installed by Repair Work Done ❑ Type of Pump H.P. I State Work Done Well Destruction ❑ Well Di meter sealing Material & Depth Dept Filler Material &Depth (}J TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I DESTRUCTION I I (No septic system permitted if public sewer is ' l available within_ 200 feet.l UJ Installation will serve: Residence Commercial _ Other Number of living units: -4— Nu bar of bedr oms �� Character of soil to a depth of 33 fee : Wats► table depth SEPTIC TANK ❑ Type Mf ..4 (�P BLP- Capacity .Z - . No. Compartments Z PKG, TREATMENT PLT. ❑ Method of�Disposal Distance t nearest: Well 142e / Foundation 1B Property Line LEACHING LINE ❑ No. & Leng h of lines Total length/size FILTER BED C7 Distance to Barest: it zA6 — Foundation �� Property line SEEPAGE PITS I I Depth Size_ C7 Number SUMPS Ll Distance to near t: Well- dtc;2 �Found tion_416011 Property Line DISPOSAL. PONDS ❑ I hereby certify that I have prepared this application d that the work will be one in accordance with San Joaquin county ordinances, state laws, and ruies and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the fo wing: "I certify th t 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 rkman's com ensation taws of California,"Contractor's hiring or sub-contracting signature certifies the(allowing: "!certify that in the performance of the rk for whi this permit is issued, I shall employ persons subject to workman's compensa- tion.laws of California." The applicant st call for I ue rns on Complete drawing n reverse side. Signed X � Title:- � Date: FOR DEPARTMENT USE ONLY "� Application Accepted by Date Q�A�reZ— �a �1 V r Grout Inspection by ate incl Inspection byw`'F Date tional 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 95201FEE gyp` INFO AMOUNT DUE AMOUNT REMITTED C SH ECEIVE Y DATE PERMIT'NO. . EH 13-24 IAEV.i i H si / u" EH—26 L/ /* 12