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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �O ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 [Ply P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES I YEAR ERPM DATE ISSUM (Complete in Triplicate) Application!1a. hereby made,to $aa Joaquin County for a permit to construct and/or install the work herein described. This application!1a made in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Servic ' Job Address E• 1AA City I Lot Size/Acreage ' - ` Q� �� 112011 L. � It $!� Ownar'a,IJame Address LlU LQ � _ Phone : Contract Address � t-ay AI/iftr] 6 . License No. Phone ��`Sj�S TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well CI - -PUMP INSTALLATION Q SYSTEM REPAIR [I OTHER ❑ Monitoring Well L7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL w OTHER WELL PITSISUMPS i e INTENDED'USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing Cl Oomastic/Private ❑ Gravel Pack O Tracy Type of Casing Specifications F] Public i"] Other n Delta Depth of Grout Seal Type of Grout I I Irrigation ' _•,._,Apprort. Depth t I Eastern Surface Saul Installed by ERepair Work Done 0 Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material d Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I flEPAi / DDITIONA DESTRUCTION I I Mo septic system permitted if public sewer is b available within 200 leet.l Installation will serve: Residence _ Commercial�_<_ Other Number of living units: Number of roams r Character of soil to a depth of 3 feet: Water table depth f SEPTIC TANK 'Ea,�Typeimfg Capacity No. Compartments PKG. TREATMENT PLT.0 Method of Disposal Distance to nearest: Well Foundation Property Line ' LEACHING LINE ❑ No.& Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Eine / fl f SEEPAGE PITS >.I:,—, Depth Size l qumber 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."Contractors hiring of subcontracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ persona subject to workman's compensa- tion laws of California." R The applicant u5 1 for att'red' spections. Complete drawing on reverse skip C V � Signed Title: mate: f^ FOR DEP RTMENT 1JSE ONLY /Arppllication Accepted by Oa4e "� Area _) /Plybr Grout Inspection bye Date inaf Inspection by ate • , d Additional Comments: - R.� Applicant — Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services r 1601 E. Hazelton Ave.. P 0 Box 2009, Stockton, CA 95201 VAN IEEE AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERM11 NO, .E19.s, E".14-26 sa26 L.