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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 ROWIT EXPIRES 1 YEAR FRAM DATE IS_S__UED (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 Services. Job Address /Vii City �_ Lot Size/Acreage / Kowne"s Name Address 1 x.1 &92 �� --- Phone �.�.� " Iva ortiractor ;�,�J Address License No. Phone TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Crl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR C7 OTHER ❑ Monitoring Well ❑ 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 n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing— Specifications F) Public El Other 11 Delta Depth of Grout Seal Type of Grout o I I Irrioauon Approx. Depth I I Eastern Surface Seal Installed by /v 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 ) REPAIR/ADDITION I 1 DESTRUCTION INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_____ Other Number of living units: Number of bedrooms Character of soil 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 LEACHING LINE Lt No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS .1 1 Depth Size Number s SUMPS Ll Distance to nearest: Well Foundation Property Line I 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 F 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: 1 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 must call for all required inspections. Complete drawing on reverse side. Signed Title: Date: apil <y+ �hhll �i, F R DEPARTMENT USE ONLY Application Accepted by v�v"�' i 3 �►-KA&SX eT._. _—.__ Date ^' res t g Pit or Grout inspection by Date . Final Inspection by N Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services q 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE 1 INFO AMOUNT DUE A OUNT REMITTED CK CASH RECEIVED BY DATE PERM1T'No. + EH 13-24(REV.F e 5F '� 1yr �( EH 14.2E CCa U l V l 4• ♦,J� ,