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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION -Ow ,R 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 P 0 BOA 2009, STOCKTON, CA 95201 PEI EXPIRES ] YEAR FROM DATE ISSUED . (Complete is 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 1662 and the Rules and Regulations of San I Joaquin County Public Health Services. t-7Q I Job Address �__.�_ � , - -- City Lot Size/Acreage ! I Owner's Name Address Phone Contractor d Address t License N 6� qfly Phone � TYPE OF WELL/PUMP: NEW WELL C3WELL REPLACEMENT ❑ DESTRUCTION C7 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS.,L.SU.MPS _ i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION S -ff'fC'A""IONS f_l Industrial ,'. ❑ Open Bottom ❑ Manteca Dia. Excavation Dia. of Well Casing Ca Domestic/Private`' .4 0,&avel Pack i C7 Tracy Type of Casing Specifications------ -- - - _ 1 I'I Public X1-1 Other to Depth of Grout Seal Type of Grout I I Irrigation pth i I 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.&.Depth . TYPE OF-SI=PTICWORK: NEW INSTALLATION l I REPAIRIADDITION i I DESTRUCTIO INo septic system permitted if public sewer is ��yyavailable within 200 feet.) Installatign�will serve: -Residence_ Commercial_ Other Number of Irv9 in "units: Number of bedrooms Character of oiQ!0a depth of S feet:t Water table depth III SEPTIC TANK. 14 ❑ T e/Mf i Type/Mfg g CapaC ty � No. Compartments PKG, TREATMENT PLT. ❑ � ! Method of Disposal Distance to nearest: Well 1 Foundation Property Line i " + ` LEACHING LINE Cl No. &'Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line 1 . SEEPAGE PITS I [ Depth Size Number SUMPS CI 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 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 far'_Zich this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." ti The applicant st call for allrequire spe, ons. Complete drawing on reverse side " Signed Tide: e . ms°�r�/✓a /`�// Date: F DEPARTMENT USE ONLY Application Accepted byC. - Area Pit or Grout Inspection by Date Final Inspection bDate �SS(Zn� Date -sem I 1. 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 INFO AMOUNT DUE AMO NT REMITTED CASH RECEIVED BY DATE (� PERMIT'NO. . EH 13-24MEv.1/95) �•d© � it a -04 EH 762e CCCC �C 1 i