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APPLICATION FOR PERMIT - t SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION AU6 0. 6 !Prp 1601 E. HAZELTON AVE. , PHONE (209)468-342t�lvl��lU�� HEALTH P O BOX 2009, STOCKTON, CA 95201 t E%P RES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES (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 Health Services. ' •�-^ r Cit �j_G/� Lot Size/Acreage Job Address �J 3 Ow er's Name // . ddress Phone !I/w""' `�0ddre f License No. Phone 9��3a� Cont for i ❑ outof TYPE OF WELLIPUMP: NEW WELL 13 WELL REPLACEMEN ❑ DESTRUCTION Monitoring well ❑ PUMP INSTALLATION�� SYSTEM REPAIR Cl a OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS '�iNT!NDED USES TYPE OF WELL PROBLEM AREA ONSTRUCTION SPECIFICATIONS X n Industrial ❑ Open Bottom F-1MantecaDia. of Well Excavation et Dia. of Well Casing gmestic/Private ❑ Gravel Pack E3Tracy Type of Casing Specifications — I'1 Public Ci Other n Delta Depth of Grout Seal Type of Grout t ti I I Irrigation —.Approx. 60_* Eastern �S ace Seal Installed by Repair Work Done U Type-of-PUMP- — --H.P.- ' - State- �k-D,4,Sealing Material & Depth _ Well Destruction ❑ Well Diamet�`—, Depth ! j -_,y Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION i I DESTRUCTION l I INo septic system permitted if public sewer is r s_avaiiabie_within-200 feet.l k f. installation will serve: Residence_ Commercial _ Other "5 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ------ ater-table-depth ,...-- F _ -_ Nb. Compartments f SEPTIC TANK. ❑ Type/Mfg -Capacity PKC. TREATMENT PIT, Cl Method,of-Disposal Distance to nearest: Wel! Foundation. ' Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line I I SEEPAGE PITS 11 Depth Size Number r SUMPS 1.1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl - 1 hereby certrfy that I have prepared this application and'that the work will be done in accordance wjih'San Joaquin county o`rdinan`ces;stair laws,anti q`J rules and regulations of the San Joaquin County '4 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 tall#or I required inspections. Complete.drawing on rave a sid � Signe6 pp��a`J — Title: Date: f FOR ARTMElYT USE ONLY r�O Application Accepted by pate Ares 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 0 Box 2009, Stockton, CA 95201 k FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT ND. INFO GASH + EH 13-24IRE V.