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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)488--3420 P O BOX 2009, STOCKTON, CA 95201 PE MIT EXPIRES 1 YEAR FROM DATE LaaM Com' f �'f !T( A°" (Complete in Triplicate) Application is hereby grade to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in conpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address4Z4 City at Size/Acreage Owner's Name �+� Address PhonOe Contractor Address ense Not Phony TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F_ DESTRUCTION ❑ Out of Service Well LI PUMP INSTALLATION D SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1� r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 11 Domestic/Private ❑ Gravel Pack L1 Tracy Type of Casing Specifications t�`1 I'! Public Cl Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Dane Well Destruction 0 Well Diameter Sealing Material &3Depth Depth -Filler Material pth TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION r DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) i Installation will serve: Residence Commercial Other Number of living units: T Number of bedrooms Character of soil to a depth of 3 feet: Water table depth -^+r SEPTIC TANK ❑ TypelMfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Indatian Property Line LEACHING LINE > No. & Length of lines1:;;x::) S(a �4_Z ----C)— Total length/size FILTER BED ❑ Distance to nearest; Well Foundation Property Line i SEEPAGE PITS 11 Depth Size _ Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 11, I hereby certify that I have prepared this application and that the work will be dobe ih 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 California." i The applicant mst I t r all re inspections. Co late drawing on re side. Signed Title: _ _ Date: FOR DEPARTMENT USE ONLY ,! r Application Accepted by Datee Area 1 Pit or Grout Inspection by Data Final Inspection by+� Date 3470 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 IMOUNT DUE AMOUNT REMITTED CCK 8 RECEIVED BY DATE PERMIT'N0. a EH 13-24 1REV.1"W 7/1-70 /1 EH 14.26 4