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"r, APPLICATION FOR PERK[I T SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 TC,_ ER1lIT EXPIRES 1 YEAR FROM DATA ISSUID (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 rade in coupliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San Joaquin County Public Healthh Services. Job Address ?. t c-1 � P ,�!_�, _ City Lot Size/Acreage Owner's Name Address ''y`r Phone NV7Cor+tractnr�rlwt�i7 Address � License No Phone 51�2—141Y TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION D Out of Service Well ❑ PUMP INSTALLATION ❑ 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 U1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing XDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I') Public 1-1 Other fl Delta Depth of Grout Seal Type of Grout I i Irrigation — Approx. Depth I l iastern Surface Seal Installed by Repair Work Done �Z Type of Pump . 5: H,P. T. State Work Done ( , Well Destruction ❑ Well Diameter Sealing Material & Depth } Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Instafiation will serve. Residence_ 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. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size c,{ FILTER BED CJ Distance to nearest. Watt Foundation Property Line SEEPAGE PITS 11 Depth Size r Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL 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 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 Cal" ia` Thea i ant must II for all require pection omple drawing on r side. Signed X Title: � R DEPARTMENT USE ONLY Application Accepted by ,,q� t Date Area ` Pit or Grout Inspection by Date Final Inspection by Data Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hatelton Ave., P 0 Box 2009, Stockton, CA 95201 CK 9 FEE INFO MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. . EH 13-21fHEV.rin510-0 EH tkr�-1] � ��3a 426 U �---��-C�.J` `} �`