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Ij APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O 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 trade in cotWliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address City Lot Size/Acreage Ft+ , � t' P � 'j Owner's Name 4" ss, ' `� t Phone J Contractor License No.d9 Phone ' TYPE OF WELL/P P: NEW WELL ❑ WELL REP[ACEMEN ❑ DESTRUCTION ❑ Out of Service Well ❑ t I 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 Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Ria. of Well Casing [.l Domestic/Private ❑ Gravel Pack n Tracy Type of Casing Specifications Il Public 1-1 Other A Delta Depth of Grout Seal Type of Grout ! I Irrigation ,_._.Approx. Depth ,p(.I Eastern Surface SealInstall_e_d by Repair Work Done 0 Type of Pump H.P. m� State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth t '� l Depth Filler Material' pth [[[ TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 0 DESTRUCTION 11,(No septic systempermitted if public sewer is "available within 200 feet.) (�} Installation will serve: Residence Commercial— Other Number of living units: 4— Number of bedrooms I Character of soil to a depth of 3 feet: ; t Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity ° No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation ._ _ Property Line l LEACHING LINE ❑ No. & Length of lines T tal:length/size FILTER BED ❑ Distance to nearest: Well `� nda%ion Property Line SEEPAGE PITS 11 Depth Sire ' t ' Number IF k SUMPS LI Distance to nearest: Well + F undation Property Line r 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 j 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-contfacting 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." 1 Afy ' The applicant m t ca r all r uir d ins ctto S. ComW,feOREiPA�RTMENT rev se side.Signed J � Date:USE ONLY r Application Accepted by Date 02 b Area 1 Pit or Grout Inspection by Date Final Inspection by ��5� /. Date I^ U Additional Comments: F 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 DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT'N0. a EH 13-24 IREV. /n 51 ✓ f �a EH:4.2e ��