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APPLICATION FOR PERMrn IT SAN JUAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION COPY 1601 E. HAZELTON AVE'.'s PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PMIT UPIRES 1 YEAR FRQM DA _ (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This F 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 f r City �(g Lot Size/Acreage C?0l1 /k QF I Owner's Name Address c� ► — Phone k Contractor Address e�/� _ License NOVs2'2/ phone 6,fAa TYPE , WELL/PU P: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial II Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C1 Domestic/Private ❑ Gravel Pack ❑ Trady Type of Casing Specifications Il Public 1-3 Other f1 Delta Depth of Grout Seal Type of Grout I I Irtioation — Approx. Depth I I Eastern Surface Seal installed by Repair Work Done ® Type of Pump H.P. State Work Done _ Well Destruction CI Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION IGF- 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 9 feat: �►'� _ — --_ _—._Water table depth 90 f SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal qti Distance to nearest: Well Foundation Property line LEACHING LINE0 No. & Length of lines .��f �. `_. _ Total length/size y FILTER BED C1 Distance to nearest: well Foundation Property Line l!l79a 1 SEEPAGE PITS 17 Depth Size 3 r� __ Number Z SUMPS LI Distance to nearest: Well clt? r Foundation /p r Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done iri 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 taws 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 applicantmust call for all r uire inspactions. Complete drawing on reverse side. (� Signed X_1[ _- ` _- Title: ©W�[� Date: r ^� �Pb FOR DEPARTMENT USE ONLY / / Application Accepted by Date _—Z 42==:: � � Area__ yC: �_j i�or Grout Inspection by Dais� rr��-426 ��6Final Inspection by %-�Pr///.rr�te�r�c—� Date' / 10 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 ASH DUE AMOUNT REMITTED RECEIVED BY r DATE �\ PERMITN{O. . EH U-21(REV.I/As) FM V�� ]v 90f ;/-2e