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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 P 0 BOX 2009, STOCKTON, CA 95201 VMIT EXP RES 1 YE R FROM DATE ISSUED (Complete in Triplicate) j Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This II application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations o: San Joaquin County Public Health SeLyices. Job Address �/ City hot Size/Acreage i Owner's Name dress ,� s Ph,, Contfac cess License No c F'tho TYPE OF W PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well_ ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR C_l OTHER D Monitoring'S,n 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications (� I'} Public I--1 Other fl Delta Depth of Grout Seal Type of Grout "1 I # Irrigation —._,Approx. Depth I I Eastern Surface Seal Installed by �] Repair Work Done 0 Type of Pump H.P, State Work Done i Well Destruction D Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION a No septic system permitted if public sewer is ailable within 200 feet.I Installation will serve: Residence��Commercial— Other Number of living units: 4— Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED I.1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 1 Depth Size Number SUMPS LI 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 for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant us c for all requixed i spectr ns. Comelet drawing o side. Signed, Title: Date: .- I TMENT USE ONLY Application Accepted by r Date 5-- Area UJA Pit or Grout Inspection by Hate Final Inspection by Date 1� b 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 OUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. I` INFO CASH t F EH1�2�41REV.rinsi S- 1 oJ�+6)v LN637 f 1-yrqv— EH D~ V r