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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 k P O BOX 2009, STOCKTON, CA 95201 EXPIRES- 1 YEAR FROM DATE ISSUED (Complete in Triplicate) r 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. Job Address I City c� 1 Lot Size/Acreage ff c Owner's Name Address Phone Contractor V Cf 1_ � 11? Address .A t)lf, "Tc)t_CLQ f'T License No Phone'M&9j277qF t TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION -❑ _ -- _ _ . .SYSTEM REPAIR- ❑ _ ,,,OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK fl nhP SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C] Industrial 0 Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing (.l Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications l'1 Public #! fa Other '17 Delta Depth of Grout Seal x Type of Grout I I Irrigation —.Approx. Depth I I Eastern - Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. tate W rk Done Well Destruction /$_ Well Diameter Sealing Material & Depths D i►1. Depth-o �d',%L K0 t Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l 1 DESTRUCTION I I INo septic system permitted if public sewer is y available within 200 laet.l j 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, ❑ Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS . 11 Depth Size -Number SUMPS Ll 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 must call for all required inspections..Complete drawing on reverse side. ! Signe Title: e<_ Note _ Date: � 1 F. DEPARTMENT USE ONLY l .. Application Accepted by !�G /� _ Date Area T✓ Pit or Grout Inspection by Date Final Inspection bye Date 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 i INFO A UNT DUE. AMOUNT REMITTED CASH RECEI ED BY DATE PERMIT NO. . EH 13-24(REV.111S15) s EH iC211