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APPLICATION FOR PERMIT SAN J'OAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL H73ALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE iSaUED- " (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 cocpllance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Reguletione of San Joaquin County Public Health Services. j r r Job Address �(D City�(_[_yn Lot Size/Acreage 1 '# Owners Name GIN ti ld t Address Phone Contractor frAddress-__ Q License No. Phone TYPE OF WELL/PUMP: M. NEW WELL ❑ 4 WELL REPLACEMENT n DESTRUCTION ❑ Out of Service We11 ❑ PUMP INSTALLATION ❑ , SYSTEM REPAIR ❑ OTHER O Iionitoring well 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 fl Industrial 1 t ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing (l Domestic/Private D Gravel Pack (1 Tracy Type of Casing Specifications .4 I'I Public } Cl Other I l Delta Depth of Grout Seal Type of Grout I I Irnuation r _.Approx. Depth I l Eastern Surface Seal Installed by Repair Work Done C Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth t Filler Material i Depth + TYPE OF SEPTIC WORK: NEW INSTALATION REPAIR/ADDITION 1 I DESTRUCTION i I (No septic system permitted if public sewer is Q r /, available within 200 feet.l Installation will seAw,-Residence_ Commercial _ Other Number of living units: ` Number of bedrooms ^� Character of Boil to a di`pthh of 3 feet t Ant�t LnCN '1 -Water table depth O SEPTIC TANK. D' Type/Mfg PtE L GpnGf.o6L Capacity &6 Q No. Compartments PKG. TREATMENT PLT, D ^ t. f t , Method of Disposal f Distance to nearest: Well . _ Foundation!440 Property Line — G LEACHING LINE "`1;'C No. & Length of lines Total Iongth/size 14 n FILTER BED \ O Distance to nearest: Well fr�j_ Foundation _ Property Line SEEPAGE PITS 1'1 Depth _ _-_ ` Size _ Number +;✓ SUMPS LI ;Distance to nearest: ``Well Foundation y Property Line DISPOSAL PONDS O r I hereby cerify 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 of licensed agent's signature certifies the following: "I certity 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 pertormence of the work for which this permit is issued,)shall employ persons subject to workman's compensa- tion laws of California." ` r The applicant must call for all reqAd inspections. Complete drawing on reverse side. t t CI Signed X Title: �,ft'[�1"1 Date: FOR DEPARTMENT US�ONLY�� Application Accepted bDate AA( Area Pit or Grout Inspection by Date Final Inspection by �.l Date / /+ d Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, tlnvironmental Health Permit/Services 1601 E. Haaelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH R 11 ECEIVED BY r DATECV6_ ERMIT N0. . EH13-24INEV.IIRS)- f ,Q q —� a�rV ' ys FN:�4a