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APPLICATION FOR PERMIT r I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES l ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 I P O BOX 2009, STOCKTON, CA 95201 �. PIRMIT EXPIRES 1 YEAR FROM DA ED (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 compllanceivith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address City v Lot Size/Acreage ^Ar aCLer Owner's Name �•�a t��o rC T Address Sri S �/Vhone 67$1 i Contractor v Address License No. Phone f 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 C7 Industrial ❑ Open Bottom ❑Manteca"' ` - Dia. of Well Excavation Dia. of Well Casing ID Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public _ 1-1 Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation 5 _Approx. Depth I ) Eastern Surface Seal Installed by Repair Work bone U_Type of Pump = +A H.P. f State Work Dane Well Destruction �❑Well:Diameter Y "Sealing Material b Depth Depth Filler Material d Depth, , TYPE OF SEPTIC WORK: - NEW INSTALLATION REPAIR/ADDITION i.I DESTRUCTION I I (No septic system permitted if public sewer is 1 available within 200 feet.) ]]] Installation will serve: Residence� Commercial_____, Other +y 11 Number of living units: Number of bedrooms^ _ }� ,• r t Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. T 15' Type/Mfg Capacity_. Zdb s[ Na'Compartments Z PKG. TREATMENT PLT. Cly _ ' Method of Disposal Distance to nearest: -Well--..2,50 Foundation� Property;Line 5'h s LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED 1-1 Distance to nearest: Welf Foundation - lg4 _ Property Line L_ rIt SEEPAGE PITS 11 Depth Size� _h ip� C�' Number - SUMPS L1 Distance to nearest: Well I.S(� Foundation. (} Property Line 6� 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, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant u all for all quir ctions. Complete drawing on reverse side. Signed X Tide: Date: OR PARTMENT USE ONLY r Application Accepted by Date Area J1 Pit or Grout Inspection by 3 Date Final Inspection by Date F Additional Comments: h i Applicant - Return a11 copies to- San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201FEE moi` p INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH7�-2etREV.tiK51 S � ,� { rJ��