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i APPLICATION FOR PERMIT I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOK 2009, STOCKTON, CA 95201 PFaMIJ EXPIRES I YEAR FROM DATE J§SUED (Complete in Triplicate) r 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 Addressty Lot Size/Acreage Owner's NaibePhone Contractor�L, � ('-0�1 _ Address License No./ 36 Phone TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION D Out of Service Well 13 PUMP INSTALLATION ❑ SYSTEM REPAIR Q OTHER ❑ Monitoring Well E7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial © Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type-of-Easing-- — Specifications i"1 Public !-1 Other ' 171 Delta Depth of Grout Seal _ Type of Grout w• I I Irrigation Approx. Depth I I Eastern Surface Seat Installed by Repair Work Done 0 Type of Pump H,P. State Work Done _ Well Destruction ❑ Wait Diameter Sealing Materiel & Depth Depth 7 Filler Material & Depth Ik`, TYPE OF SEPTIC WORK: NEW INSTALLATION I Y REPAIR/ADDITION i I -DESTRUCTION 1 1.(No septic system permitted it public sewer is h '* available within.200 feet.) Installation will serve: Residence- Commercial_ Other t r r Number of living units: Number of bedrooms r Character of soil to a depth of 3 feet: E Water table depth ! 1 1 SEPTIC TANK. ❑ Type/Mfg _ t"t7 - Capacity No. Compartments PKG. TREATMENT PLT. ❑ / ,� Method of Disposal Distance to nearest: Well dation Property Line, 1 LEACHING LINE Cl No.A-Length of-lines t7 Total length/size FILTER BED n Distance to nearest: Well foundation Property Line'',} C7 F SEEPAGE PITS 11 Depth I Sire q " Number`' SUMPS LI Distance to nearest: Well undation I D ,'Property Line _ DISPOSAL PONDS ❑ t I hereby certify that I have prepared this application and that the work will'be done in accordance with San Joaquin county ordinances, state taws, 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 compensationlaws 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, Fshatl.employ persons subject to workman's compense- tion laws of California." f �' , The applicant (Dust call for all r IF d inspection -Completedrawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE.ONLY / Application Accepted by Date —�` Area Pit or Grout Inspection by Date Final Inspection by Date b Additional Comments: _?n 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 I IF O AMOUNT DUE AMOUNT REMITTED CASH 1 CK 11 RECEIVED BY DATE PERMIT'NO. EH;4-28 EH 13-24 IREV.IINS) SLTJ � �/✓ ,5—�p p '"�� fe, l