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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 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 is made in compliance with San Joaquin County ordinance No. 549 and 2862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 7 City Lot Size/Acreage y� tOwner's Name Address Phone Contractor ss icense No. one TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION D Out of Service Well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 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 I F] industrial © Open Bottom C) Manteca Dia. of Well Excavation Dia. of"Well Casing F.1 Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications tions Public CI Other n. Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.,P. State Work Done _ Well Destruction, O Well Diameter Sealing Material & Depth - Depth iller.Material &.Depth TYPE OF SEPTIC WORK: NEW INSTALLATION l REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is t available within 200 feet.) Installation will serve: Residence iCorrrrnercial _ Other , 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. 0 � � Method of Disposal Distance to nearest: Well atiaFt � Property Line �3 O LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well ndation Y= Property Line _ EEPAGE PITS 11 Depth Size Number LIMPS LI Distance to nearest: Well Foundation Pr in Property Line 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: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all requir, d i spections. Com to drawing on rev i Signed X Title: _ Date: �EP4ATMENT USE ONLY Application Accepted bya_ � Date Area Pit or Grout Inspection by Date Final Inspection b 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 INF OUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMI7'NO, + EH 13-24(REV.IfA51O,tJV 3 O Igo —N0EH 11.25