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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 4 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 95201 EXPIRES 1 YEAR FROM DAIE ID (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. / Job Address Sd la J_ City��i� dot Size/Acreage f y i r Phone owner's Name _ 1 , r /rr r contractor Address License No. Phone TYPE OF WELL/PU P: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR L❑ OTHER ❑ Monitoring Well L] 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 F-] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing F:l Domestic I Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public i-1 Other Fl Delta Depth of Grout Seal Type of Grout Ii Irrigation _Apprax. Depth I 1 Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material-16-Depth [ TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I INo septic system permitted if public sewer is available within 200 feet.I C) Installation 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 y PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE L� No. & Length of lines Total length/sire FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll 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 became 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 ma for all requ=redinsctiona. Complete drawing on reverse side. Date: 2 �� 2�- ",/.Signed X Title: – p0 D SE ONLY Application Accepted by Date Area Pit or Grout inspection by Date Final Inspection by , �� Date / Additional Comments: Applicant – Return all copies to: San Joaquin County Public Health 4 Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P Bo 2009, Stockton, CA 95201 FEE AMOUNT DUEMOUNT REMITTED ASH RECEIVED BY D T£ PERMITNO. INFO J ♦ EH 13-N MEV.I/n 51 0— `� [ 4 1 EH Y4-2e