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APPLICATION FOR PERMIT �Sr SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 Nd � P O BOX 2009, STOCKTON, CA 95201 tv 0. ;�.1..,...,� PkEM11 EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 7. 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 S rvices. 4 � �d�`" e" Lot size/Acreage Address y� y46 Owner's Name �itfPe� `� fFtOL dress � ,t-- Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well. ❑ PUMP INSTALLATIO ❑ 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 L-1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing t7.1 Domestic/Private Cl Gravel Pack L7 Tracy Type of Casing Specifications I'1 Public is Other C-1 Delta Depth of Grout Seal Type of Grout I i Irrigation _.Approx. Depth l 1 Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction 0 Well Diameter Sealing Material & Depth Depth Filler Material & Depth (�t TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I 1 DESTRUCTION 11PTNOlo septic system permitted if public sewer is int" available within 200 feet.I Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table death �1 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments tlN•� PKG. TREATMENT PLT,El Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED I_I Distance to nearest, Well Foundation Property Line SEEPAGE PITS 11 Depth Size _ Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS CI 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, l 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 mustII for I require nspections. Complete drawing on reverse side. - G Signed r Title: Date: F RTMENT USE ONLY Application Accepted by AA Date Area Pit or Grout Inspection by Date Final Inspection by-5 �� Date U 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 IN O AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE P�ERMIT'NO� . EH 13-24(REV. /n 51 <—M /1 ry