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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 i pFJtXIJ EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made.to Sein Joaquin County for a permit to construct and/or install the work herein described. This application is trade in compliance with San Joaquin County Ordinance No. 549 and 62 and the Rules and Regulations of San Joaquin County Public H th Services. Job Address " City ` Lot Size/Acreage Owner's Name Address r V Phone [fl s L � ,t � f Contractor =Address 7� -- —.License No.. _GLP.hone.-9 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Nell ❑ i PUMP INSTALLATION ❑ S TEM REP R Z 1 OTHER ❑ Monitoring Well L7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION_ AGRICULTURE W - _ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CO RUCTION SPECIFICATIONS t f7 Industrial C7 Open t3onom ❑ Manteca r. ia. of all Excavation Ria. of Well Casing _ ' Specifications t Il Domestic/Private ❑ Gravel Pack ❑ Tracy Type o Casing t Pe I'I Public Ll Other ❑ Delta .- i. Depth f Grout Seal t Type of Grout f 3k I I Irrigation .Approx. Depth I 1 Eastern, r Surface Seal Installed by t t t [ Repair Work Done U Type of Pump ; H.P. State Work Dona _ f Well Destruction ❑ Well Diameter Sealing Material &'Depth t j _ 4 t 1 Depth r Filler Material & Depth- TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I ! '•DESTR TION I i ANo septic system permitted if Public sewer is / /'} av it _le wi 200 f et,1 Installation will serve: Residence_ Commercial ther - Number of living units: $ Number of bedrooms N Q' � _ 0/ I t Character of soil;to a depth�of 3 feet - ---- Water table depth SEPTIC TANK. I ❑ TypelMfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ k. , Method m Di sal /V Distance to nearest: ;t Well" 4 Foundation Property Line i LEACHING LINE No. & Length of lines - -- Total length/size FILTER BED # ❑ Distance to nearest. WelVJ_ Foundation s r7� Property Line SEEPAGE PITS Depth `_Size -z Number .. SUMPS LI Distance to nearest: :4 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 Jbagl C6urity— . {t I 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 j employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature i certifies the foltowi6q: 1 certify that in the performance of the work for which this permit is issued, I shall em"ptoy persons subject to workman's compensa- lion laws of Ilfornia." The applicaur cal!fo required 'nspeetions. Complete drawing on reverse side. 7 Signed X Title: 1�' Date: _ FO -OEPARTMENT USE ONLY Application Accepted by ._ �► Cda� — Date Area Pit or Grout Inspection by Date Final Inspection Da ="� Additional Comments: t ^s �` } k Applicant - Return all copies to- 'San Joaquin County Public Health ...r' I Services; Environmental Health Permit/Services t. I `� _ 1641 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 952o1- CINFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE t ERMIT'N6. EH t3-24(REV.r/x 51 + EH 94-2a I ,