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APPLICATION FOR PERMIT SAN JOAQUINtCOUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 t P, O 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 Orhnance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. i -?j 7 Job Address ry --A Lot Size/Acreage Owner's Name 1� �ddress ` i Phone y Contracts A/ , _Address i� License No. Phone I��'Ts TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ `', V, OTHER 0� Monitoring Well U j. .� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESDISPOSAL FLD. PROP. LINE i FOUNDATION .AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom "Cl Manteca Dia. of Well Excavation Dia. of Well Casing Ll Domestic/Private -❑ Gravel Pack_ ❑ Tracy Type of Casing Specifications I') Public ''" ,❑ Other F1 Delta Depth of Grout Seal-- Type of Grout I I Irrigation Appiox:.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 If Depth Depth r Filler Mater161 a Depth- TYPE OF SEPTIC WORK: NEW INSTALLATION IjF REPAIR/ADOITION I ! DESTRUCTION I I (No septic system permitted if public sewer is i available within 200 feet.) .,,Installation wilt sena: Residence�� Commercial_ Other - Number of living units: —t— Number of bedr ours Character of soil to a depth of 3 leer: w+• � ;ti!---SEPTIC TANK. ❑ Type/Mfg Water table depth �- cipacny� _ No. Compartments PKG. TREATMENT PLT. III `! - Method of Disposal 1 -` Distance to � nearest: I Well 2 Foundation d Property Line 2D 1) tr 4 i LEACHING LINE ❑ No. B Length of lines - �-1/Total length/size C+ ,� FILTER BED ❑ Distance to'nearest: I Well _ Foundation--t/.� Property Line _ .� -. / SEEPAGE PITS 11 Depth Number S-U—MRSD LI Distance to nearest: 11 ! h (1 d t 71 Foundation .n d Property Line—OLE: PONDS ❑ I'�s, :.-% I hereby certify that I have prepared this application and that the'work will be done in a rules and regulations of the San Joaquin County ccordance with San Joaquin county ordinances, state laws, and _ Home owner or licensed agent's signature certifies the followin / :t g: ' certify that in the performance of the work for which this permit is issued, 1 shell notJ employ any person in such manner as to becomeance of two to workman s compensati certifies the following: "1 certify that in the performance laws of California." Contractor's hiring or sub-contracting signature work or which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applican at I II requir l spections. mp a"drawing on re rs side. Signed X !Y'�'1/s7 Title: Data: FOR DEPARTMENT USE ONLY /� 1 Applic n Accepted by Date — O Area rout In dictron by Date�L/Final Inspection by Y Additional Comments: Applicant - Return all copies to: Ban Joaquin County Public Health 'Services, Envirotmtental Health Permit/Services :1601 E. Hatelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE[tB MOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. CASH . EH 1324(REV.vxm EH i,.]a l fro a try o� �_/�_ 9n �&_ j��