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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 EXPIRES 1 YEAR FROM DATE 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 l City of Size/Acreage Owner's Name i Contractor dress �. icense No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C1 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 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 n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing JQ r] Domestic/Private ❑ Gravel Pack C7 Tracy Type of Casing Specifications Il Public 0 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done Y Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material &'Depth'°"— TYPE OF SEPTIC WORK: NEW INSTALLATION 10' REPAIR/ADDITION I I DESTRUCTION I'I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence JZ Commercial_ Other „ Number of living units: Number of bed oms Charactef of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg _ ��"�' _.. Capacity_ No. Compartments PKG. TREATMENT PLT. ❑ - ro-- - Method of Disposal Distance to nearest: Well Foundation Property Line _ LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED C1 Distance to nearest. Well Foundation Property Line SEEPAGE PITS ( I Depth ze Number_ 13 ,. ._.�- UMP 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: "t 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 st If all requires`inspections. Co late drawing on reverse side. Signed X U Title: Date: FOR REPARTMENT USE ONLY aiApplication Accepted bG�c�`�f- Date f Area 2 rout Intfpection by Date Fina) Inspection by �(3: - Dated=t 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 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMI7'NO. ` INFO CASH ] q + I �} \+ EH i�-201REy.t/NSI l � � � I � L� I '©l C, r `