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APPLICATION FOR PERMIT r + SAN J'OAQUIN COUNTY PUBLIC HEALTH SERVICES iJ ENVIRONMENTAL HEALTH DIyISION i 1601 E. HAZELTON AVE. , PHONE 209)468-3420 ] P O BOX 2009, STOCKTON, CA 95201 r. PgMIT E%P RES 1 YEAR FROM DATE JOS I' (Complete in Triplicate) Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. :his application is made in compliance with San Joaquin County Ordinance No. 549 and r1862 and the Rules and Regulations of San Joaquin County Public Health Services. y/� 8 2 � Job Address 9� J it�` `� ty Lot Size/Acres Owner's Name Address O �Z- �� Phone -3 Z Contractor Address License No. Phone + TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well L7 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 n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Fl Domestic/Private ❑ Gravel PacI ❑ Tracy Type of Casing Specifications I"1 Public 11 Other n Delta Depth of Grout Seal Type of Grout ! I Irritation �.Y. Approx, DI ) Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump l H.P. State Work Done Well Destruction © Well Diameter Sealing Material & Depth Depth I Filler Material. & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION +<_REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence r� Commercial Other Number of living units: Numb Iar of bedrooms Character of soil to a depth of 3 feet: = Water table depth SEPTIC TANK SEL Type/Mfg° Capacity_ No, Compartments PKG. TREATMENT PLT. 0 1.1 � / Method of Disposal ; Distance to nearest: Well d Foundation� Property Line ) LEACHING LINE Z4- No. & Length of lines Total length/size !J FILTER BED ❑ " Distance to{nearest: well�L oundation Property Line G� I SEEPAGE PITS Pf- Depth Size Number t SUMPS Ll 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 pertormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applican st call for all requir�insction, Complete drawing on reverse side. Si ed X � Title:��I'�""'��1 -- . Date: !' FOR DEPARTMENT USE ONLY �3 �' Area l Application Accepted by Dat 6 � -- AdPit or Grout Inspection by Date �� Final Inspection b 1 Date'?- �• Additional Comments.- Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Servicea 1601 E. Hazelton Ave..,-F 0 2009. Stockton, CA 95201 FEE AMOUNT DUE ,) MOUNT REMITTED CASH RECEIVED BY :� ATE PERMIT N0, INFO �,�� 11,�``` /} /f . EH 19-24IRE:V,ripsi �� A. � _ � yy^ / rV � rt EH tb'1tl 7