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APPLICATION FOR PERMIT I � SAN JOAQi3IN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERidIT EXPIRES 1 YEAR_FRQM_DAIE 1AjS 1XED (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. /� Job Address _ n � 71, 'E-- City Lot Size/Acreage Owner's Name f4 r`'- , �'+� Address `s W Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Ll Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well [3 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 C] Industrial © Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing C] Domestic/Private ❑ Gravel Pack Cl Tracy Type of Casing Specifications FI Public 1-1 Other 1-1 Delta Depth of Grout Seal Type of Grout I I IrtiUation —Approx. Depth I I Eastern Surface Seat Installed by W Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction ❑ Welt Diameter Sealing Material & Depth C Depth Filler Material b Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet) / Installation will serve: yidnce_ Commercial_ ther e r� Pit 1z� etc/a tri ��A Number of living units; Number of bedrooms Character of soil to a d 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 ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest. Well Foundation Property Line 1 SEEPAGE PITS 11 Depth Sire Number SUMPS Cl Distance to nearest: Well Foundation . Property Line DISPOSAL PONDS 0 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 applic all f X211iq 'nspections. omplete drawing on reverse side. Signed Title: �� Date: 90 FOR DEPARTMENT USE ONLY �f 9 Application Accepted by Date C -! Area Pit or Grout Inspection by Date Final Inspection by Date Additlonal 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 FEEINFO l�AMOUNT DUE AMOUNT REMITTED CJASH RECEIVED BY DATE (�PERMI7¢NQO, + EH 13-24IREV.rin51 !©s 00 ?0 . 0 v /�o� ��d'�� !a" EH—20