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N_ APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL, HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 95201 PEMIT EXPIRES 1 YEAR FROM DATE lrqq (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 Heal h Services. 1 CityS ze/Acreage Job Address f i Phone Owner's Name Address r- r License N �� Phone�� Coniraclor �1 Address ^ service weli TYPE OF WELL/PUMP: NE ELL ❑ WELL REPLACEMENT DESTRUCTID ❑ Out or Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 7-1 OTHER DESTRUCTION ❑ 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 Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing D Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications 1'1 Public [:1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth l 1 Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done _ Well Destruction D Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION [Pr REPAIRIADDITION I I DESTRUCTION l 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence J_ Commercial — Other Number of living units: --I— Number of bedrooms_ � Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Df�� Method of Disposal Distance to nearest: Well EIZ-4ti^dation l - - Property Line Z5 iZ2L LEACHING LINE Q No. & Length of lines Total length/size FILTER BED Cl Distance to nearest: Well Dandelion Property Line SEEPAGE PITS 11 Depth x �Si:e Number SI POSLI Distance to nearest: Well oundation Property Lina — ' AL 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 of 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 applicant must call for a quired ins pec 'Dna Complete drawing on reverse side. Signedx I `� C� Title: Date: \ FOR DEPARTMENT USE ONLY Application Accepted by Date ` - Area r vim-. pectian by '-''' "` Date(2--'l'/-4U Final inspection by-hr`^`'� Data 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 CASH RECEIVED BY DATE PERMIT'N0. 1 .\14.25INFO Y 13.24 (REV.1114 5)