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! Ij APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION M 1601 E. HAZELTON AVE. , PHONE (209)468-3420 I I) P O BOX 2009, STOCKTON, CA 95201 is HERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) �9 /kh Application is hereby made to San Joaquin County for a permit to construct and/or install thew ein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rifles and Regulations of San Joaquin County Public Health Se i S. t f Job Address City Lo -_ Lot Size/Acreage/ II n > t Owner's Name r Address F- / ' Phone Contractor,.,e"A- Iff ?address License No. hone TYPE OF WELL/PUMP: 4 NEW WELL ❑ �� WELL REPLACEMENT _ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ . SYSTEM REPAIR n- OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL_____L_ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ti n Industrial ❑ Open Bottom ❑ Manteca Ria, of Well Excavation Dia. of Well Casing �l Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing f Specifications Il Public I-) Other n Delta Depth of Grout Seal Type of Grout I i Irrigation P..Approx, Depth I I Eastern Surface Seal Installed by Repair Work pone ❑ T n p Type of Pump H.P. State Work Dona_ Well Destruction ❑ Well Diameter Sealing Material & Depth r Depth Filler Material 6 Depth _ r� TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is V ' 'j available.within 200 feet) Installation will serve: Residence_L Commercial_____ Other i Number of living units: Number of bedrooms --- - Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. O Type/Mfg t Capacity No. Compartments PKG., TREATMENT PLT:❑ !�, �� / '� E Method of Disposal 5 ? - � Distance-to.nearest: Well' `� Foundation _` Property Line l LEACHING LINE .Cl No. & Length of tines Total length/size FILTER BED ❑ Distance to nearest Well f D lO Foundati'an 4()t� Property Line SEEPAGE PITS, 11 Depthize Number` MPS LI Distance to nes st: Welt Foundation Property Line v D SPO�SAAL PONDS p II 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 I 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'smploy persons subject to workman's compensa- tion laws of California." i The applicant st fol; requir spections. Com a drawin n rse side. Signed X Titl Date: A�l F T_USE,ONLY I Application Accepted by "t Date_ y� �1_ D Area + �� Pit or Grout inspection by . Date Final Inspection by Date � . Additional Comments: I � iiIV I 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 INFO AMOUNT DUE AMOUN MITTED I CK I CASH RECEIVED BY DATEr PERMI`TT'NO. F + EHEH%3-24IREV.IinsI 7. l.1i a� - 0_8_V C � � -J03/ � II