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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 r 49k10 r EXPIRE 1 FR DATE E2-YEAR U r (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. City �r9� 1 Lot Size/Acreage ,] Job Address VVLontiactor \\ 's Name �r �YJtc Address Phone 373 S7� Address License No. Phone TYPE OF WELL/PUM . NEW WELL ❑ WELL REPLACEMENT [7- DESTRUCTION ❑ Out of Service Well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C] 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 CI Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing fl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'I Public 1-1 Other n Delta Depth of Grout Seal Type of Grout I I lrritfation —.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done _. Weil Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth C� TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I I {No septic system permitted if public sewer is available within 200 feat.I r Installation will serve: Residence— Commercial_ Other p 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 1v PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number • SUMPS LI Distance to nearest: 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 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 al7.1a4?redinsppeet'ons. Complete drawing on reverse side. Signed Title: Date: �r3` OR REPARTMENT USE ONLY I!_ q Application Accepted by Date `F' 3^ r r Area i� Pit or Grout Inspection by Date Final Inspection by<--� Date6,-y Additional Comments: 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 1 E MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PPERMI7'N0. EEH 1 3-24 H t4•Ze 1REV.r i x s�IWO � � �. �1-3 S l,3-9 ?/— 13 0