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APPLICATION FOR PERMIT I � SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FR M DATE ISSUM i (Complete in Triplicate) t Application is hereby made to San Joaquin County for a permit to construct end/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. Yk Y �", Job Address City Lot Site/Acreage Owner's Name . Address,_ ContractorAddress License NO./ Phone d / TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ k PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ V DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE f FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j F- Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications pp � I"i Public 1-1 Other n Delta Depth of Grout Seal Type of Grout r�I I i Irrigation —..Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump r 'A.P. - - — State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Dept Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION If REPAIR/ADDITION I I DESTRUCTION l I iNo septic system permitted if ptiblic sewer is i available within 200 feet.) Installation will serve: Residence_L Commerciale Other Number of living units: ---I— Number of bedrooms # Character of soil to a depth of 3 feet: t {~ Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ _ Method of Disposal Distance to nearest: Well / D 6 Foundation j( } Property Line ro LEACHING LINE ❑ No. & Length of lines Total length/size 170 FILTER BED ❑ Distance to nearest: Well-f-167 e "Foundation 'Property Line r a Q O 1 r SEEPAGE PITS 11 depthSize _ Number aPQOPP CI Distance to nearest: Well 40-, Foundation lz-=� Property Line SD1 POSAL 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 I rufes and regulations of the San Joaquin County f 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 r certifies the followin I certify that in the rformance of the work for which this pe is issued, I shall employ arsons subject to workman's compensa- tion � Y Pe P P Y P I P tion laws of California." The applicant must call fora a uired inspecti s, Complete drawing on r e side. Signed K / *wL ?V/Z Title: Date: ��Flqg��qTMENT IJSE ONLY Application Accepted by Qa Date yy� � Area Pit or Grout Inspection by '' Date ' Final Inspection'b ! Date�� Add' ' net Comments: D t - 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 INFO {AMOUNT DUE AMOUNT REMITTED GASHif RECEIVED BY DATE PERMIT,NQ. + EH 13-24IAEV.t5 EH 34.28