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APPLICATION FOR PERMIT d SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES w, ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468--3420 P 0 BOX 2009, STOCKTON, CA 95201 APER 5! '�o,,q I HEALTH PERMIT EXPIRES 1 YEAR FROM DATE ED (Complete in Triplicate) 'jS��;VCS 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. O � ��- -!Z - p,j Job Address 4`'�� City y, Lot Size/Acreage v Owner's Name Lwq, Address /..2 r?S'fg �+ tlP.�ni� /�zY. - _ Phone Contractor �x�-L*� Addres�7�� License NoJ�s�3�� PhoneT� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION L-) Fut of Service Well ❑ PUMP INSTALLATION C3' SYSTEM REPAIR ElOTHER ❑ Monitoring Well LIST ANCE 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C�omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications C1 Public C1 Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. De h I I Eastern Surface Seal installed by Repair Work Done LST Type of Pump H.P. _ —!E State Work Done_ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION ( I DESTRUCTION l I INo septic system permitted it public sewer is available within 200 feet.) Installation wilt serve: Residence Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ A Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED CI Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line p.7 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 for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applican must call for all required inspections. Complete drawing on reverse side. Q Signed _-... ;`-'f-Title: . Date: w� r FOR DEPARTMENT USE ONLY } Application Accepted by Date �i j Area Pit or Grout Inspection by Date Final Inspection by G`'"'�l/Date Additional Comments.- Applicant omments: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 INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. . EH i3-24(AM iix51 � /��