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a 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 RE RMIT EXPIRES 1 YEAR FRQM DAIE 15SURD (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. Job Address g2 City Lot Size/Acreage j /y� Owner's Name "r' Address ~ ` Phone L/ s 0 / Contractor ess nse No. one w TYPE OF W L/P P: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELT PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 17 Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications f'1 Public 1-1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation —,Approx. Depth I I Eastern Surface Seat Installed by Repair Work Done L7 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Maiirial'&'Depth TYPE Of SEPTIC WORK; NEW INSTALLATION ljV REPAIR/ADDITION l I DESTRUCTION I I INo septic system permitted if public sewer is (� t I available within 200 feet.) Installation will serve: Residence r Commercial_ Other S Number of living units: Number of bedrooms 17 Character of soil to a depth of 3 feet: Water table depth C SEPTIC TANK. ❑ Type/Mfg .____ Capacity No. Compartments PKG. TREATMENT PLT. ❑ � n Property of Disp � Distance to nearest: Well psr y Line f1 LEACHING LINE ❑ No. & Length of lines Total length/size / FILTER BED ❑ Distance to nearest: , Well ation j Property Line SEEPAGE PITS 11 Depth Sire Number v SUMPS LI Distance to nearest: Well Foundation . Property Line 3 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, andP 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 candies 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 caU for d requi rns ctions. Comp drawing on rever Signed Title: Date: z FORpDEPARTMENT USE ONLY C�h Application Accepted by ,rE Date_ �_` v 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 FEE INFO AMOUNT�D�UUEE AMOUNT REMITTED ASR RECEIVED BY DATE PgE�RMI7 NNO�.{}� . EH 13-24rREv.Ii85l EH t�•2e