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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 BOX 2009, STOCKTON, - CA 95201 PUWIT EXPIRES 1 YEAR_FROM DATES�SU._.ED (Complete in Triplicate) Application is hereby made,to San Joaquin County y fora permit to construct and/or install the work herein described. This i application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San I Joaquin County Public Health Services. F: Job Addressr O l City �� Lot Size/Acreage Owner's Name _1 j__I +uCl Contractors f' -n Address y I G�Sr—' 1. !S� ' - License No. _ Phone - T TYPE OF WELL/PUMP: NEW WELL 41 WELL REPLACEMENT ❑' DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ©; OTHER ❑ Monitoring Well 01. DISTANCE TO NEAREST: SEPTIC TANK n— SEWER LINES I V1. __ _ DISPOSAL FLD.011-1 PROP. LINE 7.06 FOUNDATION _12— AGRICULTURE WELL OTHER WELL _.r PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing `r Domestic/Private 'Gravel Pack ❑ Tracy Type of Casing. Py`e-'`' Specifications Il Public C] Other ..FVDelta Depth of Grout Seal fi l/ Type of Grout A0A- egmenL I I Irrigation M�.Appfox. Depth I I Eastern Surface Seal installed by 1 r b10,n Repair Work Done ❑ Type of Pump H.P, jSta a Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_____ Other Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.O Method of Disposal } Distance to nearest: Well Foundation Property Line { LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number r SUMPS El Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 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 must call for all required ins coons. Complete drawing on reverse side. Signed X ►LOQ-a '-- Title: Q_A, eX .- ,.._._. Date: (Z-1{o/.,�c_ 4 FOR DEPARTMENT USE ONLY ' Application Accepted by ��+ Q , Date `-f�/ Area Pit or Grout Inspection by ;.Adr2e'[ , Date L X4,4 Final Inspection b �r�-t . n z_ P y Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P O Box 2009, Stockton, CA 95201 FEE INFO K 40 AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. Q ii IL . EH21rREY.rrnsl OO M yq� EHA-20 :1-.2e i [ 1 t r 0 V