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APPLICATION FOR PERMIT jj SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES r}l5 ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 �� P O BOR 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISQ1JED (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. 5119 and 1862 and the Rules and Regulations of San Joaquin County Public Health SerVicea. Job Address 3 is >� l31iJ DA t � .-_ City Lot Size/Acreage Owner's Name Phone Contractor_ lrp- L� h��,51,0 Address _`�.t!__ r4/J��/_? =/L`T License7i�f- Phone 3 9 7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well €� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION- --= : �AGRICUL-TURE.-WELL_ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing M Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Fl Public I:1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation -.._._Approx. Depth l I Eastern Surf aceTSeul'Instailed by Repair Work Done (3 Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter " Sealing Material-& Depth Depth Filler Material 3 Depth TYPE OF SEPTIC WORK: NEW INSTALLA •ION.I I REPAIR IADOITION-(-1—DESTRUCTION INo septic system permitted it public sewer is ' available within 200 feet.) Installation will serve: Residence T 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. 0 i Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. 8 Length of tines Total length/size r� FILTER BED ❑ Distance to nearest: Well Foundation Property Line � 1 SEEPAGE PITS ( I Depth Size Number , SUMPS CI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 Home owner or licensed agent's signature certifies the fallowing: "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 applicant must call for all required inspections. Complete drawing on reverse side. Signed X� Title:- SI-it` L Date: — F RTMENl' USE ONLY Application Accepted by Date �— �`� 'r Area Pit or Grout Inspection by Date Final Inspection by I Date 7-2 f l2 Additional Comments: t Applicant - Return all copies to: San Joaquin County Public Health k f Services, Environmental Health Permit/Services f 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'N0. + EH 13.24 IREV.t i n SY EH 34.28 r