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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION l 1601 E. HAZELTON AVE. , PHONE (209)468-3420 h P O BOX 2009, STOCKTON, CA 95201 %P RTS 1 YEAR FROM DATE (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 Prvice �A 7 �� , wt• City Lot Size/Acreage (�[Dom"``rf_ G .lob Address5L Owner's Name W'1 Address Tf� t rr L<t` Phone J f r u a�[ 7 6 -- Z Z Z to Phone. 6 /o Contrac r Address r License No. i TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT D DESTRUCTION ❑ Out of Service Well L1 PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER 0 Monitoring Well ❑ r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLU. 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 C.7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public 1-1 Other n Delta Depth of Grout Seal Type of Grout I I irrigation _Approx. Depth t I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIR/ADDITION I I DESTRUCTION I I fNo septic system permitted if public sewer is available within 200 feet) Installation will serve: Residence Commercial_ Other k Number of living units: Number of ooms ^ Character of soil to a depth of 3 feet: Water table depth fJ SEPTIC TANK Type/Mfg Capacity No.Compartments PKG, TREATMENT PL ❑ r Method of Disp?sal r!_ Distance to nearest: WellyU -Foundation Property Line �� { LEACHING LINE No. & Length of lines l Total length/size IQ FILTER BED ❑ Distance to nearest: Wall r Foundation -I / Property Line 4 _ SEEPAGE,PITSDepth CQ.5L Size_ � Number SUMPS - , Ll Distance to nearest: Well _ Foundation O 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 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: "1 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 m all for allU_ U" inspections. Complete drawing on reverse si Signed Title: Date: -,`�FOR-DEPARTMENT USE ONLY j Application Accepted 4�— — Date ,6 r Area ` /Pjyor Grout Inspection by C�- ? Final Inspection by ata (/Additional Comments: ;. Applicant — Return 911 copies to: San Joaquin County Public:.Health f Services, Environmental Health_Permit/Services `— 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201V\5, FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'N0. INFO CASH G i1�} 2 + EH 13-24 EHt1.24IREV.I/Hsi r 1 G � i�J