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APPLICATION FOR PERMIT SAN' ,JAQUIN COUNTY PUBLIC HEALTH S 1ICTS 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 grade to San Joaquin County for a permit to construct and/or ineta3l the work $e�,scrhii, n No. Ir and 18b2 and the Rules eeepppggg g�fati a f, an application is made in compliance with San Joaquin County Ordina ce 5 9 Joaquin County Public Health Services. _ Job Address l City Lot Size/Acreage Owner's Name Address Phone Contractor � �� Address Litense No. " Phon TYPE OF WELL/PUMP: = NEW WELL ❑ WELL REPLACEMENT IJDESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring;Nell ❑ ` 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 L1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'I Public Cl Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ { .Well Destruction D Well Diameter Sealing Material & Depth Depth Filler Material A Depth TYPE OF,SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION i+yDESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet I Installation will serve: Residence Commercial_ Other Number of living units: _J__ Number ^'bedrooms _ r Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartfiients PKG. TREATMENT PLT. ❑ `f Method of Disposal j Distance to nearest: Well Foundation Property Line LEACHING LINE 134'eNo. & Length of lines �_� Total length/.size s FILTER BtD C1Distance to nearest: WeII /�O Foundation Property;line ad r SEEPAGE PITS K4-- Depth - `Size �, , Number SUMPS Cl Distance to nearest. Well T U Foundation i Property1ine do DISPOSAL PONDS O ,r hereby Certify that I have prepared this application and that the work,`.wilf be done in accordance,with San Joaquin county ordinances, state-laws, and rules and`reguiations of the San Joaquin County,- Home owner or licensed agent'• -signature-conifies-.the following: "t certify that in the perfbrmance of the work for which this permit is issued, I shall not employ any person in such mariner 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 ihie perform$nce of the work for which this permit is.vsFued_I 0.4llemplpy persons subject to workman's compensa- tion laws of California." , The appli st call tar all r uir inspections.`Complete drawing on verse side. J Signed r Title: Date: FOR DEPARTMENT USE ONLY �7 Application Accepted by Date /te t/ Area�pE= �yor Groot Inspection by -Final Inspection by loetez 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 AMOUNT DUE AMOUNT REMITTED GK t I RECEIVED BY DATE PERMIT NO. INFO EH;4•2e 111 l 1 ��11