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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOA 2009, STOCKTON, CA 95201 REMIT-EXPIRES 1-YEAR FROM DATE ISSJU (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 1662 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address /72City Lot Size/Acreage �a ' Address Owner's Name Conti act 0 Address .Q, E�e2k.167 License No.�ZgZZ Phone ?P4S Es7� TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT C] DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O Monitoring Well C7 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 J C7 industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing P Domestic/Private ❑ Gravel Pack E) Tracy Type of Casing Specifications I'! Public (-I Other 1-1 Delta Depth of Grout Seal Type of Grout N I I Irrigation Approx. Depth l 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 Depth filler Material 8 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I QEfAIR/,ADDITION ffDESTRUCTION I I No septic system permitted if public sewer is ' available within 200 feet.) Installation will serve: Residence Commercial—. Other Number of living units: __L__ Number of b rooms %3 r Character of soil to a depth of 3 feet: Water table depth S� SEPTIC TANK. >� Type/Mfg Capacity AaBd No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well 649 Foundation Property Line_L2______� LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I i SEEPAGE PITS 11 Depth Size X loo Number .twAAQ,,);< Distance to nearest: Well_ sl'0 Foundation Property Line -5E 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, 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 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 applicant st call to l required inspections, Complete drawing on reverse` ) Signed X Title: _ y Date: Q C7 FOR DEPARTMENT USE ONLY Application Accepted by — Date Pit or Grout Inspection by Date Final Inspection by _ Date ZO rL� Additional Comments: f 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 SASH K N RECEIVED BY / DATE G�PERMIIT'N17. . EH 13-14MEV.ri�5) 1 l �r ofr o fi��G, rj (� [��Z�J'�] � l`"(c/gl EH 14-n