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APPLICATION FOR PERMIT a -Nzz 01es SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 MIRES 1 YEAR FRQM DATE ED (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. f Job Address - City Lot Size/Acreage Owner's Name dress Phone Contractor C: ddress cense No/�� Phonr TYPE OF WELL/PUMP: NEW WELL 13 WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L-} industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing [.] Domestic/Private ❑ Gravel Pack L1 Tracy Type of Casing Specifications Il Public f_1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _..ApproK. Depth t I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & D pth TYPE OF SEPTIC WORK: NEW INSTALLATION I I R€PAIWADDITION (V DESTRUCTION I I (No septic system permitted if public sewer is r available within 200 feet.) Installation will serve: Residence_____ Commercial_ Other t 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. Compartments PKG, TREATMENT PLT, ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines �LcTotal length/size ( '\ FILTER BED ❑ Distance to nearest: Wells_ Foundation Property Line 42 lJ SEEPAGE PITS l I Depth Size Number SUMPS Cl Distance to nearest: Well Foundation _ d Property Line DISPOSAL PONDS ❑ I hereby cenify that ! 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(tiring 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 mut I fa all re a inspections. C p drawing on raver a side. Signed Title: , � . ,.„ pate: DEPARTMENT USE ONLY Application Accepted by Date ____ =�Z 9 _ Area CP or Grout Inspection by Date inal Inspection by Dale 0 / Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Enviroomental Health Permit/Services 1601 E. Hazelton Ave., P 0 Sox 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH .!RECEIVED BY DATE PERMIT"NO. . EM13-24(REV.s/Ksl /�L i 1/1 � r y� l�'+i r.k EK 7420 l�V �j � ] ) «� I [