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~ APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION � 1601 E. HAZELTON AVE. , PHONE (209)46$-3420r�� P 0 BOX 2009, STOCKTON, CA 95201 E� _ BO411 �� P Y ]' )EXPIRES 1 YEAR FR 9 DATE ID NE ' �; Complete in Triplicate), 7 �� T4 �' nJ[ t!S it .4�[_►�r4,G Application is hereby made-to San Joaquin County for a permit to construct and/or install the work here c�r� This application is made in compliance 4ith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Re�� fj�an Joaquin County Public Health Services. } ,(,� /�� p s ' 9 v]d►�`shY F City /�a40t Cdt Lot Size/Acreage 3• 1 GS Job Address �r fJ �G�t Address a� J 4iya s r"p` Phone �$) 72(9��70 Owner's Name n Q t PY7 �/ �,¢ r Icense No "� Phone q1d� 7?/DlZ Contractor �> � Address 7 'r /L; TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT EJ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Monitoring Well E� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROF ZINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE. TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI N ,fes ❑ Industrial ❑ Open Bottom v ❑ Manteca Dia. of Well Excavation Dia. of Well Casing L D Domestic/Private Ll Gravel Pack ❑ Tracy 'type of Casing Specifications I'1 Public -1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Wrk Don Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION rl DESTRUCTION I I iNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— 'Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg ..i Capacity No. Compartments PKG. TREATMENT PLT. ❑ # Method of Disposal Distance to nearest: Wet] Foundation Property Line LEACHING LINE ❑ No. & Length of"lines Total length/size FILTER BED ❑ Distance to4nearest: Well Foundation Property Line SEEPAGE PITS I I Depth 1 Size Number � SUMPS L] Distance tornearest: Well Foundation Property Line DISPOSAL PONDS ❑ r� 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 applic nt must call for all required inspections. Complete d0onde. _ J NQ�40 Signed X r _WL4' . L(iC-- rf �" ! /� Ddte4 E ONLYApplication Accepted byDate Area Pit or Grout Inspection by Date , .Inspection by Dare Additional Comments: �f�` /!7 35 Applicant - Return all copies to: San Joaquin County Public Health— � 4 ~� + Servicesi-Environmentai Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'ND. INFO CASH } + CH44.2E 3.241REV.i/est r� t y y8Sr l3 �1 EH 4