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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 i PFJtMIJ 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 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. ee Job Address �r Q l T 4c,,SUM - City yf(:;L1kZ-vitiLot Size/Acreage Owner's Name .O Addresses 0 t.e� �t yZt.- )__/Phone �, 7 Contractor to 1/, Address License No. Jot I N7 )iI --7Phona 71 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT1-7OESTRUCTION�I'Out of Service Well ❑ PUMP INSTALLATION C] SYSTEM REPAIR ❑ OTHER ❑ Monitoring cell 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 a� F--] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing CI Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications Il Public 1=] Other n Delta Depth of Grout Seal Type of Grout 11 Irrigation ._.Approx. Depth I I Eastern Surface Seal Installed by -� > Repair Work Done C] Type of Pump H.P. State Work Dona Well Destruction Fj Well Diameter �J Sealing Material & Depth 9th"` Depth d (. filler Material & 'Depth TYPE OF SEPTIC WORK: NEW INSTALLATION [ I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.I Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line E LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED CJ', -Distance to nearest: Well Foundation Property Line `U SEEPAGE PITS 11 Depth, Size Number �- SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL. PONDS 0 I� 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 applicant must call for all required inspections. Complete drawing on reverse side. Signed Title: jeogvy ✓ a Date: I r F05,DEPARTMENT USE ONLY t 1 1 4 Application Accepted by Date Off! Area �T ctrt.[l wa>; ' Pit or Grout Inspection by Date Final Inspection by gr Af Date Additional Comments: 6 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 a FEE AMOUNT DUE AMOUNT REMITTED I CK# RECEIVED BY DATE PERM17'NO. INFO CASH AA C� f� I + EH13-21tREV.riKa1 /?i,00 . E� y EH 14-28 if 1