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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1.601 E. HAZELTON AVE. , PHONE (209)46$-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATHI_SSUM (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 City (-OLD Lot Size/Acreage Owner's Name - Address # �'`�U��'t �� - Phone 3 -3 Contractor' �~La—t � _ Address' -License No.-' Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well [D PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ '� r r OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLP. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL 'PITS/SUMPS ! t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing tI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications t Public CA 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 0 Type of Pump H.P. State Work Done_ _` Well Destruction ❑ Well Diameter Sealing Material & Depth_ - r' `�. Depth Dep Filler Material & Depth . . TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I INo septic system permitted it public sewer is I r ' available within 200 feet.) Installation will serve: Residence At Commercial_ Other l t Number of living units: Number of bedrooms Character of soil to s depth of 3 feat: 3J � 4-►' ,^-- - -» Water table depth SEPTIC TANK ❑ r Type/Mfg + cz t Capacity f{90M. -_ No. Compartments # a _.� PKG. TREATMENT PLT. ❑ Method of Disposal a �` �." f sp � Distance to nearest: Well Foundation Property Line f LEACHING LINE ❑ No. &"Length of lines Total length/size FILTER BED F1 Distance to nearest: Well Foundation Property Line 5 SEEPAGE PITS l Depth Size as, Number �- SUMPS Ll iDistance to nearest: Well ,Rl+ Foundation 10 '`Property Line f{O ' DISPOSAL PONDS ❑ t I hereby certify that I have prepared This' pplication and that the work will be done in accurdance 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 periormance 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 signatot certifies the following: "I Certify that in the performance of the work for which this permit is issued, !shall employ persons subject to workman's campensa- tion laws of California." ' The a ant must call for a re ctions. Complete drawing on reverse side. Sig Title: _�4��:�_C � T Date: -- FITMENT USE ONLY Application Accepted by Date ' .-;�9 -90 Area Pit r Grout Inspection b ,1��v..�� Date (J Final Inspection b Data f 0 G Additional Comments: Applicant - Return all copies tod San Joaquin County Public Health + Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 } INFO FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PEERMI N0 a EH 13-24(REV.1/x5) ?© 00 Q r� �� FH 7126 / Dr