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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 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This 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 �� / /L� � � City roc Lot Size/Acreage Owner's Name } �� f� Address l %=Xf �4 Phone 3C��33 Contractor ► 1 Address_ vI— License No._36IS2-21 Phone a TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ 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 F1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing [I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F] Public (1 Other n 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 ❑ Well Diameter Sealing Material & Depth r Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ILK 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 3 feet: ��_ CI, Water table depth SEPTIC TANK IY Type/Mfg Capacity 4l'.__W No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well 4Ptl Foundation Property Line LEACHING LINE 1141-No. & Length of lines To at length/size L FILTER BED ❑ Distance to nearest: Well _ Foundation > �� Property Line SEEPAGE PITS h.✓Depth U Size _ Number SUMPS LI 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 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 applicant must call for all requir ins ctions. Complete drawing on reverse side. Signed X Title: e[`.� 11_ Date: FOR DEPARTMENT USE ONLY [A/p\plication Accepted by Data Area /PiUor Grout Inspection by Date t}�-� 6Final Inspection by 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 I CK INFO AMOUNT DUE �� AMOU`NN1T REMITTED CASH � /RECEIVED BY l� TE �^ PERMIT NO. . EH 13-24(REV.ii M 5) ' I�". (J �..l �� l V" � Ic: L� — /Ll .�c.✓li?� lr EH A 26 _ !!