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� I r APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES /� 7 ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE, , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 'PERMIT EXP,IRT$_1 YEAR FROM DATESI SUED (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 ` f City Lot Size/Acreage Owner's Name " Address * Phone Contractor Address License N -Phone` —AU�- TYPE F WELL/PUMP: NEW WELL ❑ WELL-EIERL-A•CEMENTT❑ DESTRUCTION 0 Out of Service Well ❑ Monitoring Well l _ _PUMP INSTALLATION- SYSTEM REPAIR D OTHER ❑ # U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP: LINE FOUNDATION AGRICULTURE WELL OTHER WELL ; iINTENDED USE TYPE OF WELL PROBLEM AREA- XO.NS,T,RUCT1.0CATIONS. ; Cl Industrial ❑ Open Bottom ❑ Manteca Pia. a Excavation Dia. of Well Casing C7 Domestic/Private d: r-❑ Gravel Pack ❑ Tracy Type of Casing— asing Specifications - i'1 Public, rl,Other (l Deptfti.of Grout Seal Type of Grout 4 I I irrigation — -Approx. De I 1 Eastern Surface SeLI`Installed by ' Repair Work Done L7 Typa--of gyp' ',' �`H.P. — — r State Work-Done_ r a Well Destruction © Diameter i Sealing Material,�&& Depth Depth . .,,.Filler Material & Depth _ TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is 'k available within 200 feet.) i Installation will serve: Residence's'Commercial—"" Other Number of living units:. _"Num`be�af'etlr oms Character of soil toa diplh of 3 feet: - Water table depth SEPTIC TANK- Type/Mfg Capacity No, Compartments PKG. TREATMENT PLTL❑ 'i Method of Disposal Distance to nearest: Well d Foundation Property Line _ LEACHING LINE Mo. & Length of lines Total length/size FILTER BED C1 Distance to nearest: Well O 4r Foundation Property Line SEEPAGEPIT J� Depth :5f Sire _ Number SUMPS ; El Distance to nearest: Well Foundation Property Line k i DISPOSAL P'O( DS%:, ❑ t I I hereby certify that I have prepared this application and that the work wilt 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 performheww ance-of-tork for which this permit is issued. I shall not employ any person in such manner as to become subject to workman';s-compens4f h laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the perfgrmance-of-th8 work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant ust call for all fequ ed inspections. Complete drawing on revere side. t Signed Title: Date: /0'"7"7—,r� 3 FOR DEPARTMENT USE ONLY s Application Accepted by Date�'� Area/ Pit or Grout inspection by Date Final Inspection b 0 Date Additional Comments: Applicant - Return all copies to: Sen Joaquin County Public Health 'Services, Environmental Health Permit/Services " 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 n INFEO AMOUNT DUE AMOUNT REMITTED CK 9 CASH RECEIVED BY DATE PERMIT•N0. EH 13-24 IREV.1iK5) EH 14•26