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APPLICATION FOR PERMIT rE 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 i &ED (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 Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. �� Lot Size/Acreage C3 /� Job Address Y - r Owner's Name D L�� / -,_Address A Phone < � Contractor /Y S ddress License No.A=rm t e=e Phone TYPE OF WELL/PUMP: NE WELL WELL REPLACEMENT n_ DESTRUCTION Q Out of Service Well 0PUMP INSTALLATIO SYSTEM REPAIR 0 OTHER © Monitoring well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES r DISPOSAL FLD. —_ PROP. LINE _ FOUNDATION a�Q AGRICULTURE WELL ::: ' OTHER WELL PITS/SUMPS v INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ---[w Domestic/Private ravel Pack ❑ Tracy Type of Casing Specifications FI Public CI Other r Delta Depth of Grout Seal Type of Grout �y I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. -j State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth r Depth Filler Material & Depth to TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet,) Installation will serve: Residence____ Commercial— Other Number of living units: Number of bedrooms �V\ Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: WeII Foundation Property Line "SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation . Property Line DISPOSAL PONDS ❑ l hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, a 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 subcontracting 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." The applicant st I au equire ns. Complete drawing on rev rse side. Signed Title: Dater FOR DEPARTMENT USE ((NLY o I Application Accepted by Date `o (� Area Pit r Grout I ctian by � D/ate Final Inspection byDate Additional Comments; I11 -,16 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 INFE BUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. . EH1321(REV .rin51 /_ pU� EH 21.26 L V (J V rO cC�_lCJ I