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APPLICATION FOR PERMIT i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION �OLJ ry 1601 E. HAZELTON AVE. , PHONE {209)488-3420 P O BOX 2009, STOCKTON, CA 95201 I'I PMWIT EXPIRES 1 YEAR FROM DATE ISSUED 9 (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 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. lJob Address v)3(V 1 City Lot Size/Acreage �b Owner's Name Address Phone Contraia / Address , U License NO3—Z9_Z __ Phone & `5l AU TYPE OF WELL/PUMP: jjl NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L] 'DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ; FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIrICATIONS C7 Industrial L].�Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 0 Domestic/Private D'Gravel Pack 0 Tracy Type of Casing Specifications I'I Public (:p�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 _ L7 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Delpth Filler Material &"Depth i TYPE OF SEPTIC WORK: NEW INSTALLATION I I EPAIR/ DDITION DESTRUCTION I I INo septib system permitted if public sewer is '1 !/ available within 200 feet.) Installation will serve: Residence_ Commercial___ Other Number of living units: _ Number of b0groorns Character of soil to a depth.of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line I No. & Length of lines L45 Total length/size a FILTER,BED LZ Ii�Distance to nearest: Well_j�aFoundation f Property.Line .!L: _ 4 fl SEEPAGE PITS I I ,I Depth Size Number SUMPS LI ! Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ e I hereby canify 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 I ! 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-tor which this perniit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant t call for al r uir d inspections..Complete drawing on reverse Sid�� ` 1 Signed X Title: � Date: j�. FOR DEPARTMENT USE ONLY „ Application Accepted by Date { Area 3j Pit or Grout Inspection by Date Final Inspection by - Date h' Additional Comments: h Applicant - Return all copies to: San Joaquin County Public Health 'j Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009. Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT N0. INFO ` CASH _ . EH13.24( IAEV.IIH5) l il*�� � ;j