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APPL I CATION FOR PERK[I T SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES � 7 [�Q < ENVIRONMENTAL HEALTH DIVISION / 1601 E. HAZELTON AVE. , PHONE (209)468-3420 11 P O BOX 2009, STOCKTON, CA 95201 EXP RES 1 YEAR FROM DAIE ISSUBP (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 Ban Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health rviices. f Job Address 21/ `� Cl /e City + z r" Lot Size/Acreage yf Address Owner's Name AV Contractor t� U A&v Address V �2 Like se No. �✓� PhoneM7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring well 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 Am © Open Bottom C] Manteca Dia. of Well Excavation Dia. of Well Casing Amestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'I Public 1-1 Other I-1 Delta Depth of Grout Seal Type of Grout A I I Irrigation ,/ _.Approx. Depth l I Eastern Surface Seal Installed by `hJ Repair Work Done LK Type of Pump H.P. State Work Done '=7 (�} Well Destruction ❑ _Well Diameter Sealing Material & Depth " Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION l I DESTRUCTION I I (No 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 t(� Character of soil to a depth of 3 feet: Water table depth Ci SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ' PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation .Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED 1-1 Distance to nearest, Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 license signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any peso such mann r as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the follo ing: "I certify Ylat in the pe ormanc he work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of C Ifornia." The applican must r equir late awing 0 sid /J Signed Title: Date: If- ~ TMENT USE ONLY I� C�`/,(-.�� ` Application Ao"pted by4Date v "____t Area �{t Pit or Grout Inspection by Date Final Inspection by GA,J Date Additional Comments: Applicant — Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Razelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOLAT REMITTED I CK RECEIVED BY INFO CASH DATE PERMIT N0. + EH1 •24IREv.1/R55 115 r 01D6" �a G'f� ?IJ � 8K EH 21.2E ///��