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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 -PERMIT EXPIRES I YEAR FROM DATE ISSUED (c (opy (Complete is Triplicate) Application is hereby made to San,Joaquia County for a permit to construct and/or install the work herein described. This I 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 4. City An§ Lot Size/Acreage II �� 1 Owner's Name —�--- _- tA gp� Address Phone _ , Phone d� Contracto( . Address �✓' 21g -14 License No. �rld u`S Phone �� TYPE OF WELL/PUMP: I NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Nell ❑ PUMP INSTALLATION 1-7) SYSTEM REPAIR ❑ OTHER ❑ Monitoring well ;l DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE. ii FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 industrial y C1 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑;Domestic/Private ❑ Gravel Pack L1 Tracy Type of Casing Specifications f'I Public 1-1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation 1� —.Approx. Depth I i Eastern Surface Seal installed by Repair Work Done ❑ Is Type of Pump H.P. State Work Done T Well Destruction E ❑ s Well Diameter Sealing terial & Depth i H Depth` Filler Mat ial b Depth JP TYPE OF SEPTIC WORK: NEW INSTALLATION ( 1 REPAMIADDITION V1 DESTRUCTION I I INo septic system permitted if public sewer is I ravailable within 200 feet.) ^ Installation will serve: .jEResidence 6 Commercial_ Other Number of living units:,�, Number of bedrooms Character of-soii'to a depth of'3 feet: Water table depth SEPTIC TANK �,❑ Type/Mfg Capacity No. Carnpartments . PKG. TREATMENT PLT.;❑ I Method of Disposal Distance to nearest: Well �.Ga Foundation D Property Line 5 LEACHING LINE Ll No. & Length of lines r- 0 Total length/size FILTER BED ❑ Distance to nearest: Well % C9 Foundation — Property Line SEEPAGE PITS I. I 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 subcontracting 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." ii The applicant us call all re"' it inspections. Complete drawing on reverse side. Signed Title: Date: i" FOR DEPARTMENT USE ONLY E� - Application Accepted by ;, it. Date - Area 12, ,._ Pit or Grout Inspection bi Date Final Inspection by Date Additional Comments: ii Applicant - Return all copies to: San Joaquin County Public Health 9n is Services, Environmental health Permit/Services 1601 E. Hazelton Ave., F 0 Box 2009, Stockton, CA 95201 FEE AMOUNT,DUE AMOUNT REMITTED CK INFO 1 y� CASH RECEIVED BY DATE PERMIT"NO. r EH 13-24(REV,i/NSI EH f �J�' �l� /y;x.28 j s�C _9 C