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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 made in compliance with San J quip County Ordinance Ho. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. �C G Job Address City Lot Size/Acreage Owner's Name � -Address Phone Contractor-__�� Address License No. F � Phone b _M7 TYPE OF WELL/PUMP.�t , NEW WELL 0 WELL REP CEMENT ❑ DESTRUCTION ❑ Out of Service We21 ❑ ' 4 PUMP INSTALLATION O 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 -�T1(PE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial <<0-'Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ` 1:7 Domestic/Private _❑ Gravel Pack r ❑ Trac .� Type of Casing Specifications i I'I Public (--1 Other *.y P.Delta Depth of Grout Sea( Type of Grout I I Irrigation _ Approx. Depth~ I I Eastern Surface Seal Installed by Repair Work Done ❑- Type of Pump ' H.P. State Work Dane_ Well Destruction © Well Diameter * Sealing Material & Depth f Finer Material & Depth ` 1 Depth , TYPE OF SEPTIC WORK: NEW INSTALLATIOREPAIR/ADDITION ( I DESTRUCTION I 1 INo septic system permitted if publjc sewer is � ..,..-- -A - 4, — —available withiri 200 feet.) Installation will serve: Residence I— Commercial Other Number of living units: Number of bid'rooms I * tt 3 Character of soil to a depth of 3 feet: Water table depth n SEPTIC TANK ❑ Type/Mfg Capacity 4? No. Compartments PKG. TREATMENT PLT. ❑ dr r le Method of Disposal -- L� Property Line,�� Distance to-nearest: Well Foundation LEACHING LINE 0 No. & Length of lines Torsi length/size r ! ! FILTER BED ❑ Distance to nearest-. Well Foundation /J� Property Line i SEEPAGE PITS 1 l Depth -Size G+ er Number '�3 SUMPS Cl Distance to nearest: Well fi Property Line d0 r /} = DISPOSAL PONDS " ❑ — _ _ _ _ I hereby certify that I have pirepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, arid rules and regulations of the San Joaquin County , i 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 shalt 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-Callfotnia.,' _ -�- - The applicant mu for all re ' d inspec'ons. Complete drawing on reverse side. 4 Signed X Title: .__ __ Date: FOR DEPARTMENT-USE ONLY Application Accepted by Date Area or Grout Inspection by ate Final Inspection b,( , Date r 7 i 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 95201FEE t INFO , AMOUNT DUE AMOUNT REMITTED CK 0 RECEIVED BY DATE q PERMIT'N0. a.-EH 13.26 TREY. �0~� t� 2-3 �-1:H 44-26