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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH •DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 .I P O BOX 2009, STOCKTON, CA 95201- IpERMIT EXPIRES 1 YEAR FROM DATE '+rSSUEP I (Complete in Triplicate) S Application is hereby made to SaarJoaquin County for a permit to construct and/or install the work herein described. This application is made in compliance 4ith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Servic s. ` 3 �Q City Lot Size/Acreage Job Address d ess Phone Owner's Name &75e&,ense Contractor iA ress No./ ?hon TYPE OF W LL/P P: NEW W L ❑ 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 L7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic I Private ❑ Gravel Peckjl" ❑ Tracy Type of Casing Specifications I"i Public (-I 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 EJ Type of Pump H.P. State Work Done O WeII Destruction ❑ Well Diameter,� i Sealing Material & Depth Filler Material & Depth Depth , TYPE OF SEPTIC WORK: NEW INSTALLATION I Ir REPAIR/ADDITION f I DESTRUCTION I I (No septic system permitted if public sewer is �f available within 200 feet.I Installation will serve: Residence Commercial T Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg t_ Capacity No. Compartments PKG. TREATMENT PLT. ❑ r Method of Dyspo l Distance to nearest: well .!Dl� Foundation� Property Line LEACHING LINE L1 No. & Length of lines Total length/size Distance to nearest: Well FILTER BED ❑ DisFoundation c3 Property Line_, d _ T� '} j SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Wel! Foundation _ Property Line _ ; I� DISPOSAL PONDS ❑ I 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, ! 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," I I The applicant must ca I fo II require ins ctions. Co p e drawing on verse side. / Signed X Title: Date: c FOR DEPARTMENT USE ONLY Application Accepted by IV Data zFe Pit or Grout Inspection by Date Final Inspection by Date j 'i Additional Comments: ' Applicant — Return all copies tP. San Joaquin County Public health I i Services, Environmental 8ealth Permit/Services l 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 f FEE AMOUNT DUE ( AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NO, lMfO . CH 13-24 �f � F EH 7..I4 F