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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES � l ENVIRONMENTAL HEALTH DIVISION ` 1 is 1601 E. HAZELTON AVE. , PHONE (209)468-3420 d L Lo k- of" P 0 BOX 2009, STOCKTON, CA 95201 DERMIX EXPIRES 1 YEAR FROM DATE ISSUED (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 ie made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. 0Q/ k l Job Address C257-2 � �Cf - a� -' City Lot Size/Acreage {" Owner's Name Address t� __ Phone� Contractor Address License No?'�`r 'OV Phone 0 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT.❑ LI O DESTRUCTION ut of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C1 # Monitoring 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 R Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I ' C7 Domestic/Private ❑ Gravel Pack L1 Tracy Type of Casing Specifications � (`l Public t-1 Other n Delta Depth of Grout Seal 4 Type of Grout i I IrriHatian �.Approx. Depth i 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P, State Work.Done Well Destruction ❑ Well Diameter SeaXing Material & Depth R = De th Filler Meterisl.- Depth •� r t p TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION i DESTRUCTION I I INo septic system permitted if public sewer is I available within 200 feet.] i installation will serve: Residence Commercial Other r 1 Al Number of living units: ___L__ Number of oms . s 6 Character of soil to a depth of 3 feet: Water table depth " SEPTIC TANK ❑ Type/Mfg �'e Capacity• No. Compartments PKG. TREATMENT PLT. ❑ ,L Method of Disposal .10 Distance to nearest: Well �^f Foundation - 'I ' Property line € k " len Total th/size y� LEACHING LINE &0"No. & Length of lines ' g FILTER BED y 1-1 Distance to nearest: Well ',,7-5_/ Foundation I,rOProperty Line �5 ! i SEEPAGE-PITSt I✓Depth Size�_ oftSize t SUMPS LI Distance to nearest: Well /. 7 L_ Foundation Property Line e- DISPOSAL PONDS ❑ k 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 I 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 s employ any person in such manner as to became subject to workman's compensation laws of-Cal'if6—rn:" 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 must call for all re ire inspections. Complete draside— ,quire) I Signed Title: Date: i I _ . SE-ONLY p M lication Accepted by ' Date ^.t7 d� 1 .Area r _ it 'r Grout Inspection by t� 17ate ^z Y �Final Inspection by Date Yv F Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Bax 2009, Stockton, CA 95201 FEEAMOUNT DUE AMOUNT REMITTED CK RECEIVED By DATE PERMIT"N0. ]NFO CASH a EH t3-24[REV.t i x 51 �J �'a _ O EH 114.26 t � a