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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ScAi X"IFD ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BO% 2009, STOCKTON, CA 95201 PRUIT UPIRES 1 XAM FROM DATE (COmplete in Triplicate) Application is hereby aade,to San Joaquin County for a permit to construct and/or Install the work herein described. This application is Stade in cotlPliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address f ';? City�IOZA:61exlol Lot Size/Acreage .� Vowner's Name �'-'"I ` �`' 0 Cd1*6 I Address / U �+�2 W7' Phone = �; AContractor Address License No. Phone YPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Bell ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well ❑ DISTANCE 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 C7 In ustrial ❑ Open Bottom C1 Manteca Dia. of Well Excavation Dia. of Well Casing C11'Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'1 Public 171 Other fl Delta Depth of Grout Seal Type of Grout ~ I I Irrigation Approx. Depth I I Eastern Surface Soul Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Wall Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 lNo septic system permitted if public sewer is available within 200 feel.) 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 ❑ TypsiMfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal QL Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. b 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 Lino DISPOSAL PONDS ❑ I hereby conify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, end 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 la f California." eg a t must call for squired ins tioga Complete drawing on reverse side.Title: c-�} ,� Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Arae Ph or{trout Inspection by Date / Final Inspection by p/ Date. �12, � Additional Commsnts: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2000, Stkn, CA 95201 IEEE AMOUNT DUE AMOUNT REMITTED CASA RECEIVED 9Y DATE PERMIT-NO. . EH 1b11(REV.URS) �( -�= � S/� EH 14.26 Err\\\ Y T