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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 BOX 2009, STOCKTON, CA 95201 pEMIT 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 workherein described. This application is made in compliance with San Joaquin County Ordinance No. 5h9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address / v V ---- �r f City Lot Size/Acreage Owner's Name ''e��r- �� '-- Address f ST Phone Contractor `ALL __Address �� 1 /12��iff License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Servibe Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 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 D Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ITracy Type of Casing Specifications Il Public El Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work pone U Type of Pump H.P. ; State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth �} Depth Filler Material & Depth 1U� TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION l I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_L_ Commercial Other Number of living units: 4... _ Number of bedroo s 3 Character of soil to a depth of 3 feet: .Cl l(S l>ca &.k ay __ Water table depth SEPTIC TANK © T e/Mf _ 4 _ .T" '_ Type/Mfg g _ ��_ Capacity No. Compartments PKG. TREATMENT PLT.❑ a7— Method of Disposal Distance to nearest: Well T Property Line �f) LEACHING LINE 14 No. & Length'of lines *�/�J`V? T Total length/size FILTER BED L] Distance to nearest: Well ll9Q Foundation F� Properly line . fir I� SEEPAGE PITS 11 Depth Sirs Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Q 1 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 5 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 certity 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." i The applicant must call for all requi ed inspections. Complete drawing on reverse side, i t c T Signed , Title: Date: _ 7/j- !/ ' FOR DEPARTMENT USE ONLY t I Application Accepted by Date c1 Area I Pit or Grout Inspection by # Date Final Inspection by ate Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services _. 1601 E. Hazelton Ave.,-P O-Box 2009,-Stockton, CA• 95201-FEE --� INFO AMOUN�rr�T DUE AMOUNT REM9T-T,ED ,CASH RECEIVED By DATE QPEHM-17yNO, . . EH13-21,REV.,/n51 ��+-7r. - !�`�6�(p# • , EH 91.2E