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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES SCANNED ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 } PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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. x r Job Address /� A417-710v City _ Lot Size/Acreage Owner's Name a w_--Address !'� /� Phone Contractor ddress License No. Phone 1C31 TYPE OF WELL/PUMP: NEW WELLWELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER O Monitoring U DISTANCE TO NEAREST: SEPTIC TANK --STSEWER LINES ".-' DISPOSAL FLD. � PROP. LINE FOUNDATION __L2_—_L_ AGRICULTURE WELL -- OTHER WELL_J_-5__ PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation f _ Dia. of Well Casing Domestic/ ravel Pack ❑ Tracy Type of Casing n- Specifications I"1 Public 1-1 Other n Delta Depth of Grout Seal / Ty/pe of Grout / 1�/i�it// I I Irrigation Ak Approx. Depth I I Eastern S ce Seal Installed by A 1a.��s5 Repair Work Done ❑ Type of Pump H.P. Z Z-7— State Work Done_ Well Destruction ❑ Well Diameter Sealing laterial & Depth Depth Filler Material & Depth e� 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 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 Ll No. & Length-of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size _ Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 perfor once of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Cali The ,pp ca r qu' s. Complete drawing on rovers 1 0. Signed tle: 'f Date: OR D ARTMENT USE ONLY Application Accepted by A Date �_1��l Area I i G Pit or Grout Inspection by —~' 5 � Date Final Inspection by .T(� _ Date 1!L 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 INFO AMOUNT DUE AMOUNT REMITTED CK If I CASH RECEIVED BY V-17-47o9o- DATERMIT'NO.EH 13.211REV.1/"5) t "--C, �t�Y� 7