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A APPLICATION FOR PERMIT 'o r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. BAZELTON AVE. , PHONE (209)468-3420 P O BO% 2009, STOCKTON, : CA 95201 PER1[I1 E%PIRES'_L_YEAR FRQM. DATE ISSUIP r (Complete in Triplicate) + Application 1s hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in corpliance with Sen Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address City a; �� i f '' Lot size/Acreage Owner's Name Address "I.r ` ' Phone r ; i _ tl f rJ t l :.. S', 1� `f'+°.✓`!' '`License Not. c,.-1 . ri! `r!.• Phone Conlracitu rY• I Address TYPE OF WELLIPUMP: NEW WELL Q' WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION 13SYSTEM REPAIR ❑ OTHER ❑ Monitorirt� Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION. AGRICULTURE WELL OTHER WELL PITS/SUMPS I '- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom p Manteca Dia. of Well Excavation +f ' :Dia. of Well Casing Cl Domestic/Private QfGfavel Pack ' ❑ Tracy Type of Casing— -' _ '✓ Specifications . I•I Public 1-1 Other n Delta Depth of Grout Seal Type o1 Grout ' I i Irrivation —Approx. Depth t I Eastern Surface Seal Installed by r`� +`r i f Repair Work Done D Type of Pump H.P. tate Work Done r Sealing Materiel i Depth 1 r.d L;' Well Destruction ❑ Well Diameter f ' Depth `^l ! 'fra< Filler Material i Depth i TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION l I DESTRUCTION I I INo septic system permitted if public sower is available within 200 feet.) Installation will serve. Residence_ Comrhercial— Other ' Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Companments I PKG. TREATMENT PLT. ❑ Method of Disposal t Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED n Distance to nearest. Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby cenify that I have pfepared 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 cenify 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 11 required 'IRspections. Complete drawing on reverse side. Signed X } ;'l Title: `' Date: 'f i� FOR DEPARTMENT USE ONLY 5r ' Application Accepted by {��_____rP�, 4 Data Area Pit or Grout Inspection by Date Final Inspection by 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 AMOUNT OVE AMOUNT REMITTED CASH a RECEIVED BY DATE PERMIT NO. • 3-24(ACV.lin6i EHS/. �"" .I.'�`.} .. :�f'...� r i.w.'ri 'f .� ""i-^ w '1 `'nj,.;,}• � �`� 7