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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 RERMIT EXPIRES 1 YEAR FROM DAIR 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 Services. Job Address City Lot Size/Acreage 1 Owner's Name _ 1j'Y✓ �f `� Sh Address _ _ rY�'�'�. „ ,,,._,,,,,,•,� Phone sj 7� 'C -Yf t/Phvnel Contractor Address License No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLA EMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ '• OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. - PROP.'LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing f. : ❑ Domestic/Private Ci Gravel Pack`. ❑ Tracy Type of Casing Specifications I"I Public (.1 Other n Delta Depth of Grout Seal Type of Grout ^ 11 Irrigation _.Approx. Depth",,. I 1 £astern Surface Seal installed by Repair Work Done U Type of Pump '' H.P. ; State Work Done Well Destruction ❑ Well Diameter `Sealing Material & Depth Depth e +. Filler Materiel & Depth I f ' TYPE OF SEPTIC WORK: NEW INSTAL-L-ATION I 1 REPAIR/.AO.DITION - DESTRUCTION i I INo+septic system permitted if;public sewer is r s - '1� - •^ available within,200 feet.I F R Installation will serve: Residence V Commercial Other �. Number of living units: Number of bedrooms .r { �•-� : . Character of soil to a depth of 3 feet: ' "+ t Water table depth y SEPTIC TANK ❑ Type/Mfg f Capacity No. Compartments PKG:'TREA�TMENTPLT..C ` ° ". f' Method of Disposal = Distance t6•neatest: . JWell Foundation'- Property Line t LEACHING LINE ❑ No&'Length of lines! Total length/size FILTER BED C7 Distance to,nearest:., v Well Foundation Property Line SEEPAGE PITS 11 Depth _ � �5izepL f -- _ Number i SUMPS L3 Distance to nearest: Well X02 Foundation 10OFr` Property Line ,/4�21V 10� f DISPOSAL PONDS ❑ 'r i f` 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 applica II fo �d iris tions. Complete drawing on reverse side. i Signed X Title: Date: ' FOR DEPARTMENT..US:E ONLY i Application Accepted by Date 2 . kZZ— Area ar Grout'lnspection by Date /y Final Inspe tion by Date 'e J Additional Comments: _ Applicant - Return-all copies io:713an Joaquin County Public Health * Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 r INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. 1. . EH 13-241REV.iiH51 EH i4.28 4 I