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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 0 BOX 2009, STOCKTON, CA 95201 MU MIT EXPIRES I 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 1$62 and the Rules and Regulations of San Joaquin County Public Health �Services. •} Job Address P� D^ /y1'L City Lot Size/Acreage Owner's Named s Phone F Contractor �ddress License NoX �31Phone o TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 171 DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OVER 0 Monitoring Well 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 C] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications i1 Public CI Other Cl Delta Depth of Grout Seal Type of Grout 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 & epth Depth Filler Material Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION DESTRUCTION I I iNo septic system permitted if public sewer is available within 200 feet.1 Installation will serve: Residence— Commercial— 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. ❑ ( ` Method of Disposal Distance to nearest: Well ZIrL.L_ Foundation k_7_J::Q Property Line LEACHING LINE Cl No. & Length of linesTojal length/size FILTER BED n Distance to nearest: Well 0 Foundation _1,� 12 - Property Line SEEPAGE PIT1 1 Depth Sire r32 Number SUMPS 0 Distance to nearest: Well IQ6 i 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: "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: 1 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 applicantstjqllt r all re �irdinspections. omplete drawing on reverse side. / Signed Title: —a� pate: 6 f FOR DEPARTMENT USE ONLY T: Application Accepted by _ Date Area Pit or Grout Inspection by Date Final Inspection by Date v� Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Y_A Services, Environmental Health Permit/Services �+ 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK 11 1 CASH "RE�CEI{VEED BY DATE PEAMIT'NO. EH 13-24 IREV.iYNS) �]L/ 1 r "\L EH t4•2a .00e