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APPLICATION FOR PERMIT C9 `t SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1 ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOR 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made'to Sen 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. i Job Address City Lot Size/Acreage Owner's Name Ad dress Phone Contractor I /IAI�evAddress C- License No. Phone TYPE OF ELL/PUMP: NE WELL.Cl t WELL REPLACEMENT ! r DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER El Monitoring Well 0- DISTANCE TO NEAREST: SEPTIC TANK- SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION 'AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom, 0 Manteca Dia. of Well Excavation Dia, of Well Casing 1.7 Domestic/Private ' ❑ Gravel Pack 0 Tracy Type of Casing Specifications CI Public ! ill Other 11 Delta Depth of Grout Seal Type of Grout I i Irrigation Approx. DepthI I Eastern Surface Seal Installed by n Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction d' Well Diameter Sealing Material & Depth Depth Filler Material pth f TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION FI DESTRUCTION I I INo septic system permitted if public sewer is I` available within 200 feet.I �L_! Installation will 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 - .❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 r Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE D No. & Length of lines __ _ Total length/size FILTER BED [1 Distance to nearest: Well _, Foundation Property Line 0-1 tkEEPAGE PITS 11 Depth Size NumberJ MPS Ll Distance to nearest: Well 12 t!5 Foundation! Property�Line.�_ DISPOSAL PONDS © Ii I hereby certify that I have prepared this application and that lKe 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 i 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 ust calf for all re I nspections. Co pI drawing an rev arse side. / Signed X Title: Date: FOR DEPARTMENT USE ONLY q i Application Accepted by Date__�—'^ t1 ^.Area Pit or rout Inspection Date �0 Final Inspection by Date Additional Comments: Applicant - Return all copies to, San Joaquin County Public Health :i Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT'DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMiT'N0. i . EH 13-24{REV.iia5) s�, f t '.t7Q / I•� 7rl�' f �1�S; EH t4-26