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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 i EXPIRES 1 YEAR FROM DAT ED (Complete iu 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 coutpliance with San Joaquin County Ordinance No. 5119 and 1862 and the Rules and Regulations of San Joaquin County Public W.Health Services. 1 Job Address 6-5-4 , _ City r Lot Size/Acreage Owner's Name 9 d ress Phone =& I< Contractor Address License No, Phone3^ L/` TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION 11SYSTEM REPAIR ❑ OTHER Z1Monitoring Nell ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Ca Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'l Public (-I Others n Delta Depth of Grout Seal Type of Grout t t 11 Irrigation , _.Appr ox. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Weil Destruction ❑ Welt Diameter Sealing Material & Depth i Depth 1 Filler Material & Depth 1 TYPE OF SEPTIC WORK:. NEW INSTALLATION I 1 REPAIR/ADDITION>< DESTRUCTION I I (No septic system permitted it public sewer is • available within 200 feet.) installation will serve: Residence T Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ TypeAmg Capacity ,No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line � I , LEACHING LINE N" No. & Length of lines d Total length/size 00 FILTER BED ❑ Distance to nearest: Well Z oundatlo A a Property Line SEEPAGE PITS 11 Depth Size _ Number I SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS . ❑ 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: "1 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 worts for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." ? Theapplicant st.call for all re ired inspections. Complete drawing on reverse side. / C� Signed X Title: _ Date: FOR DEPARTMENT USE ONLY Application Accepted by Date „��`,,. ..,„`,( Area Pit or Grout Inspection b Date Final Inspection b /r,,,.G� \ Y p Y -< - Date Additional Comments: �`{ti`- �__t!-P�[ _/in�a-Q I /b dog ��/r�e Tna�S 47 I6e �— Applicant�� Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services -ke 1601 E. Hazelton-Ave., P 0 Box 2009, Stockton, CA 95201 a[EMOUNT FEE DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT�NO. . EH 13-24 IREV,r/x 5 �� 114 PD 1�q ,l3 ,qI %&26 EH 1428