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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 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 1662 and the Rules and Regulations of San Joaquin County Public Health Services. ..v Job Address ■�+ • City& Lot Size/Acreage Owner's Na �iEOV + Address —[�.�J . '�"'CA1___ Phone lE't.D&A)�TAddress L—.f.+I .�CJfCr� � - �.l Contractor License No.e� Phone 465�� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ r 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 1 C] Industrial D Open Bottom ❑ Manteca Dia. of Well E=xcavation yi Dia. of Well Casing CI Domestic/Private ❑ Gravel Pack L3 Tracy Type of Casing Specifications I'1 Public is Other f-} Delta Depth of Grout Seal Type of Grout I i Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump ---' H.P. State Work'Done Weil Destruction ❑ Well Diameter t Sealing Material & Depth Depth + Filler Material & Depth, TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION 16or DESTRUCTION i I INo septic system permitted if public sewer is t� available within 200 feet.) Installation will serve: Residence_ Commercial&Other Number of living units: Number of oms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. W—Type/Mfg d Capacity I No. Compartments PKG. TREATMENT PLT. ❑ 1 1 Method ,of TDD)posal Distance to nearest: Well Foundation Q Property Line V LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: WeA Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done iri accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Home owner or lic nsed agent's signature certifies the following: "t certify that in the performance of the work for which this permit is issued, I shall not employ any pars n such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the folio Ing: "l certify that in the ormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of C 'f rnia." Th I- a u call for all re ed insAect' ns. to drawl o er a side. r 4�6 Signed X Title __ Date: �- FOR.DEPARTMENT USE ONLY Application Accepted by Date �S d� ly Area Pit or Grout Inspection by Date Final Date Inspection b f ' ✓ 7 as � Y 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 INFO AMOUNT��DUUEE AMOUNT REMITTED CASH 1RRECEIVED BY DATE r�PERMIT'NO. + EH 13-21EV.i/rss� D�r5 r] ��-�/ EH 14•2a