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APPLICATION FOR PERMIT `� 1 Na " . y k SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 /Jop JREMIT F"IRRS 1 YEAR FRAM 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 Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Sery es. Job Address Cjty !Lot Size/Acreage 6 P xOwnar's Name Address `^^-a-� _-_ Phone ` �w jCRY I(Corttractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCT N ❑ Out of Service Well L-1PUMP IN ST) N ❑ SYSTEM REPAIR ❑ ER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK EWER LINES DISPOS D. PROP. LINE FOUNDATION AGRI URE WELL ER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CO CTION SPECIFICATIONS C7 Industrial ❑ Open Bottom ❑ Manteca Die. of Well:E,, tion Dia. of Well Casing E l pornestic/Private ❑ Gravel Pack ❑ yType of CasiSpecifications f"1 Public Ci Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation rox. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material & Depth (A Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION f I REPAIR/ADDITION I I DESTRUCTION) I (No septic system permitted it 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: Water table depth + SEPTIC: TANK. O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE L-) No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest. Well Foundation Property Line SEEPAGE PITS 11 Depth 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, an 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 applican st call for all r qu" tions. Complete drawing on reverse side. �(Signed Title: pate: FOR DEPARTMENT USE ONLY Application Accepted by Date Area C2 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 gyp( 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'N0. INFO CASH . EH14-26IR£V.rin5l .t.b / EH14-26 �` ;•� Ip