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APPLICATION FOR PFAMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 95201. PERMIT EXPIRES 1 YEAR FROM DATE ISSUBP (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 ervi es. Job Address ! City Lot Size/Acreage Ad n� Owner's Nam r Address , Phonev r Contract ' Address Pl/ / License No-L-3,792-L 1,rPhone TYPE OF WELL/PUMP" NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ _ _SYSTEM REPAIR C1OTHER O Monitoring Well L� DISTANCE TO NEAREST:, SEPTIC TANK `SEWER LINES DISPOSAL FLD, PROP..LINE .31 FOUNDATION •`AGRICULTURE WELL- OTHER WELL PITS/SUMPS INTENDED USE ` t TYPE OF WELL -PROBLEM AREA CONSTRUCTION SPECIFICATIONS `, Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia; of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'I Public 1-1 Other I71 Delta Depth of-Groui Seal Type of Grout I i Irrigation _.Approx. Depth t I Eastern Surface Seul,lnstalled by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction © Well Diameter Sealing Material Depth Depth Filler Material 8 Depth TYPE OF SEPTIC WORK: NEW INSTAL TION t I REPAIR/ADDITIO DESTRUCTION I I lNo septic system permitted if public sewer is available within 200 feet) Installation will serve: Residence_ Commercial Other Number of living units: Number of b Ins� Character of sail to a depth of 3 feet: A Water table depth (/ SEPTIC TANK 0 Type/Mfg. Capacity No. Compartments PKG. TREATMENT PLT: 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines 7orat length/size FILTER BED {.I Distance to nearest: Well fZ_ Foundation Property Line_ [ t SEEPAGE PITS Depth Size N ber' 7 SUMPS 0 Distance to nearest: Well Foundation /4 -Property Line 5-- DISPOSAL PONDS CI 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: '9 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 st calf f r I re uired inspections. Complete drawing on reve�76' , Signed Title: Date. y Rza"*A ZI/ FOR DEPARTMENT USE ONLY r7 Application Accepted by Cern - _ Date Area L P' or Grout Inspection by�yv\ Date Final Inspection byavYy 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 , IFEENFOAMOIiNT pt1E AMOUNT REMITTED CASH 41 RECEIVED BY DATE PERMIT'NO. . EH 13.24 4REV.1 5) ` /p EH 34.26 ! / 1,0