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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 O BOR 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE IS$ JUED (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. IO Lot Size/Acreage f Job Address /'� f 1 D J I Owner's Name IJ f��.b� 7`111J7 Address 3U F. I L� Phone j -! LL Address License No.Y�I�t Phone ' Contractor —TYP_.E.OF.W.ELL/P.UMP.:..—.,,...._.,.,.-,NEW_W.ELL..❑.T; ., WELL,REPLACEMEN7 ❑ DESTRUCTION 0 Out_of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0O7HER:Q Monitoring Well ❑ _-- • DISTANCE TO NEAREST: SEPTIC TANK "SEI+IIER`L'INES ---•-- -. _DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE.' • TYPE OF.WELL ;PROBLEM AREA CONSTRUCTION_SPECIFICATIONS n Industrial ❑ Open Bottom a ❑ Manteca Dia. of Well Excavation Dia. of Well Casing EI Domestic/Private ❑ GrWel Pack ❑ Tracy Type of Casing Specifications I'4 Public i-1 Other i I1 Delta ", Depth df Grout'Seal Type of Grout Y I I Irrigation __Appro't. Depth I I Eastern Surface Seal Installed by w Repair Work Done 0 Type of Pump State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth i TYPE OF SEPTIC WORK: NEW INSFAI.LATION IMPAIR/ADDITION I I DESTRUCTION I I lNo septic system permitted if public sewer is t available within 200 feet,I installation will serve: Residence��Commercial_ Other Number of living units: _�_ Number of bedrooms Character of soil to a depth of 3 feet S Water table depth SEPTIC TANK EL_-1:We/Mfg t>^ Capacity Z,� No. Compartments �`- PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation 5 - Property Line LEACHING LINE V No. & Length of lines -r4 Total length/sire FILTER BED fl1 _DisrVhce to near st: Well Foundation /01-_ Property Line D l f SEEPAGE PITS I I Depth r Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ t I hereby certify that I have prepared this application and that the work.witlbe-done-in-accofdance 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." e mu t call or all qui ins con C Mb— swing o reverse side Si Title. drY4 /p/f / Date: FOR DEPARTMENT USE ONLY �y0 Application Accepted by Date � �d r Area Pit or Grout Inspection by Date Final Inspection by �� Date ... 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 AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT NO, INFO �] CASH `' . EH 19-24[REV.1/nSl /oI ov 'a, Ov E �I EH i4$e f 4 -