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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 1Y (PERMIT EXPIRES 1 YEAR FROM DATE ISSUED. 1 (Complete in Triplicate) t Application is hereby made to Sad Joaquin County for a permit to construct and/or install the work here described his 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. y Job Address C=C92 !S City &014,ot Size/Acreage Owner /"/'s Name ) Address ..411V -/x�?� ' Ol' Phone/ � -0, � I 1 Contractor i+ Address License No. Phone i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 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 y n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing M Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i'I Public CI Other i I1 Delta Depth of Grout Seal Type of Grout I I Irrigation ,_._ Approx.'15epth I I Eastern Surface Seal Installed by Repair Work Done L7 Type of Pump; H.P. State Work Done r Well Destruction ❑ Well Diameter Sealing Material & Depth Depth . 'E Filler Material & Depth NZ TYPE OF SEPTIC WORK:. NEW INSTALLATION LI REPAIR/ADDITION I DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence i Commercial T Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: rt `' ' " *~ Water table depth SEPTIC TANK ❑ Type/Mfg; .g. Ca acity No. Compartments �p PKG. TREATMENT PLT. ❑ ' 1 M g � Method of Disposal k Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size I FILTER BED ❑ Distance to nearest: WeEI { Foundation Property Line {� - SEEPAGE PITS { I Depth Size Number -f" SUMPS LI Distance to'nearest: Well 'Foundation Property Line DISPOSAL PONDS ❑ 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 d 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." 7. a "Y 4 s The applicant st call f 11 uired inspec'ons. Complete drawing on reverse side, Signed X Title: Dater ONLY Application Accepted by Date Area l Pit or Grout Inspection b Date Final Inspection J y n pectitsn by Data 2 Additional Comments: Applicant - Return all copies to: eSan Joaquin County Public Health IServiceB, Environmental Health Permit/Services 1601 E. Iiazelton Ave., P 0 Box 2009, Stockton, CA 95201 INFO OUNT DtJE NNT REMITTED CAS RECEIVED BY DATE PERMIT'NO. /� . EH 13-25(A EV.+i e ml `n _ [�� / CJu - -to y '7 1— �V V 1 EH i5-2li vl+