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�k APPLICATION FOR PERMIT r.f SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 gFiWIT EXPIRES 1 YEAR FROM DAT E (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. d iAG! c,- City Lot Size/Acreage Job Address r , g'k Address � `-e- Phone , Owner's Name _ r _ ._ _. r - Phone � License No.al Conti' foA — c well Ll TYPE OF WELLPFUMP. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out Mfon toring Well ' PUMP IN ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL 'PITS/SUMPS_-_ r,�,. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS '' C7 Industrial ❑ Open Bottom: El Manteca Dia. of Well Excavation Dia. of Well Casing' Cl Domestic/Private ❑ Gravel Pack C] Tracy Type of Casing Specifications Type of Grout I'1 Public I-1 Other ❑ Delta Depth of Grout Seal W I i IrrigationApprox, Depth I I Eastern Surface Seai Installed by 'x H.P. Siate Work Done— Repair Work Done [7 Type of PumpI L Sealing Material Depth i Well Destruction ❑ Well Diameter -- -. - Depth +f � Filler Material dr Defth- TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 -REPAIR/ADDITION DESTRUCTION ( I lNo.septic system permitted-if..public sewer is I _ , available within 200 feet..)_,,,., j A Installation will serve: Residence Commerclalf Other Oth _ o �...,�- -- -�.. Nurnber•of living units: �— Number of bedrooms- _ Y Character of soil to a depth of 3 feet: ' f -Water table deptffp SEPTIC TANK Type/Mfg $ CapacitY-44A No. Compartments `. _. PKG. TREATMENT PLT. ❑ A t r Method of Disposal v� Property Line Lam. Distance to nearest: Well ��n :..... Foundation P Y � ota LEACHING LINE No. & Length,of lines ( ,,�- >jllength/size ; FILTER BED (1 Distance to nearest: Well—C) Foundation Property Line nr- SEEPAGE PITS 11 Depth Size +lumber r gUMpgDistance to nearest: Well �f5r— Foundation 15 Property Line ^ i I DISPOSAL PONDS ❑ � Joaquin county ordinances, state laws, and I hereby certify that I have prepared this application and that the work will be done in accordance with San rules and regulations of the San Joaquin County that in the performance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature certifies the following, "I certify 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 canify 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 uired inspections. Complete drawing on reverse side. _ Date: Signed c, FRR DEPARTMENT USE ONLY Application Accepted by Date Area 5� Date Final inspection by Data l �� Pit or Grout Inspection by Fr�� '' Additional Comments: Applicant _ Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services' 1601 E. Hazelton Ave., F 0 Box 2009, Stockton, CA 95201 i FEEAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMI7'NO. INFO fir+' 1 �i di a EH 13-24(REV.111151 W fy EH S!-2e