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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 rJob uin County Public Health Services. �] Address �P tc .i) ,� r.C� L_Q"tS EP 110ar( City (: Lot Size/Acreage S 7 7 /�-c_ r's Name dC`r2 �\1 11 S Address l'aGll Phone - �� Contractor 5 Address License No. Phone ---TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well D 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 1� Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 11 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F) Public 11 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 U Type of Pump H.P. State Work Done _ 6 Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION IX REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence I Commercial Other Number of living units: Number of bedrooms _ Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg - P� CapacityDdQQ_0`111LNo. Compartments 3' PKG. TREATMENT PLT. Ll Method ol Disposal qq ,,�� Distance to nearest: Well Foundation -, Property Line LEACHING LINE No. & Length of lines Total length/size Ly FILTER BED C1 Distance to nearest: Well_17- 100 Foundation Property Line _ } SEEPAGE PITS 11 Depth Size _ Number is 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." r The applic nt ust call for all ctions. Complete drawing on reverse side. (X Signed X Title: C Date: FOR DEPARTMENT US ONLY Application Accepted by Date "/ Area Pit or Grout Inspection by Date Final Inspection by Date 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 AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERM17 NO. INFO CASH T'EH 13-24(REV.I/n 5) Q EH 942E l t O p G - / I