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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 PERMIT 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 1862 and the Rules and Regulations of San Joaquin County Public Health Ser ices. Job Address * Citz�oc L&anLot Size/Acreage Owner's Name /..G4fkt- /%ld d& Address Phone I Contractor Address License N, Phone TYPE OF WELL/ UMP: NEW WELL ❑ WELL REPLACEMENT _ DESTRUCTION Ll Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 Ll Industrial ❑ Open Bottom ❑ Manteca Dia- of Welt Excavation Dia. of Well Casing 17 Domestic/Private ❑ Gravel Pack L3 Tracy Type of Casing_ Specifications (.1 Public C) 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 ❑ Well Diameter Sealing Material & Depth Depth Filler Material & pth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION DESTRUCTION I I INo septic system permitted if public sewer is �a�•,3 �4') (,�(� available within 200 feet.l Installation will serve: Residence_ Commercial ther ��" Number of living units: Number of.bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacityr No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well undation Property Linet— LEACHING LINE ❑ No. & Length of lines _Total length/size Q FILTER BED 1-1 Distance to nearest: Well e&6r Foundation Property Line 4� SEEPAGE PITS 11 Depth } Size Number SUMPS Ll 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: "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, I shall employ persons subject to workman's compensa- tion laws of California." The applican must all for II requi spections. Ca le rawing on nreverse side. / Signed Title: C G Date: r FOR DEPARTMENT USE ONLY Application Accepted by Date - ( Area 2 k L� Pit or Grout Inspection by Date Final Inspection by 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 DUE AMOUNT REMITTED I CASH RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV.,/H5) C� Q� jI EH 14-24 ! j