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I� APPLICATION FOR PERMIT IE SAN JOAQ UIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION i 1801 p•OHAZELTON BOR 2009�,vSTOCKTON, CA E. , PHONE ^3420 95201 I XP RES 1 YE R FROM D T � (Complete in Triplicate) in wcl Application is hereby made San Joaquin County forpermit county-ordinct ance ando1862gtall and theERules and eRegul.ationsdof-Ban s pP application is made in ccmjliance with San Joaquin y Joaquin County Public Heaith Services. 1.k ,., •_� �I; City Job Address Lot Size/Acreage 1 � .. x � �i��-t G Phone w A J Address Owner's Name 'j ,�_ 31 1't�P License No. Phone Contractor a Address - { WELL REPLACEMENT L7 DESTRUCTION ❑ Out of Service Well i� NEW WELL� - -� -- -. '� .OTHER p - Monitoring Well TYPE OF WELL/PUMP: SYSTEM REPAIR C7 _ PUMP INSTALLATION I. L PROP. LINE,.. i a ` SEWER LINES �� DISPOSAL FLD.� PITS/SUMPS DISTANCE TO NEAREST:'SIPTIC TANK' �> a r AGRICULTURE WELL OTHER WELL—— FOhUNDATlON .� — INTENDED USE TYPE OF WELL PROI3L, ARE A CONSTRUCTION SPECIFICATIONS Dia. of Well Casing Dia. of Well Excavation ?Z—A- n - r Ci industrial XOpen Bottom ❑ Manteca r _ Specifications ❑ Tracy Type of Casing pomesticlPrivate GZ Gravel Pack Depth of Grout Seal � Type of Grout f'1 Public I:1.Other n Delta I I Irrit}ati°n aL .Approx. Depth t I Eastern surface Seal Installed by Repair Work Done (3 Type of Pump ¢-- H P State Work Done _ Sealing Material & Depth T WellDestruction ❑ Welt Diameter ��--- Biller Material 6 Depth I Depth 11,11,11,11, lNosystem ' TYPE OF SEPTIC WORK: NEW INSTALLATION.t I REPAIR/ADDlTION I ! DESTRUCTION l ! available1w thin 200 feet.) ed if public sewer is Installation will serve: Residence Commercial— Other E Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: Capacity No. Compartments SEPTIC TANK ❑ Type/Mfg Method of Disposal PKG. TREATMENT PLT. 0I Property Line Distance to nearest: Well Foundation — Total length/size LEACHING LINE ❑I No. & Length of lines Property Line ' FILTER BED [- Distance to nearest: Well Foundation Sire Number I SEEPAGE PITS I I': Depth Property Line SUMPS O'l Distance to nearest: . Well Foundation ` DISPOSAL PONDS I hereby'cenify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and k rules and regulations of the-f San Joaquin County Home owner or Licensed agent's signature certifies the following: 111 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 parsons subject to workman's compensa tion laws of California." The applicants must cal for•all required ins ctions. Complete drawing on reverse side. �- ' ( Date: Tithe: Signed X OR TPARTMENT USE ONLY a -7 Date L Area /L Application Accepted by � � y Pate Pit or'Gr t Inspection by ate Final Inspection by Additional Comments: I Joaquin County Public Health Applicant - Return all copies to: San Services, EnvironmentalHealth Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 CK RECEIVED BY DATE PERMIT'NO. FEE AMOUNT DUE AMOUNT REMITTED CASH INFO EK 13-24(REV.I/n5) 1�'','1�!.•t 31A 4�4.�� EH 34-2d II _... _....