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i 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 PPRMIT EXPIRES 1 YEAR-FSM 12ATE IS$ JUED ' (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 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address ��`�� 4City)WoW C4nVe Lot Size/Acreage Owner's Name 4r L Ip �� __ Address Phone rr w t � Contractor/�� 4-��a-_J[11vr•cf ' Address ��{1hr ? '/PF_c 7Y.. !� ea License No,d.,A"9z gm _Phone r. TYPE OF WELL/PUMP: l NEW WELL ❑ WELL REPLACEMENT ❑ +'"` DESTRUCTION ❑ Out of Service well ❑ 'X '� PUMP INSTALLATION ❑ SYSTEM-StPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPPC TANK' -SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE t: TYPE OF-WELL'' PROBLEM AREA CONSTRUCTION SPECIFICATIONS f 1 Industrial .❑ Open Bottom ❑ Manteca y Dia. of Well-Excavation Dia. of Well Casing I Y 3i' - '_.. - 'V:,J . D Domestic/Private A-111 Gravel Pack; C] Tracy Type of Casing _Specifications ' f f'1 Public i- I-1 Other ❑ Delta Depth of Grout Seal Type of Grout + I I lrrigation —.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L3 ' Type of Pump. H.P. State Work Done Well Destruction p "_Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I ' REPAIR/ADDITION DESTRUCTION i I (No septic system permitted if public sewer is f/ available within 200 feet.) Installation will serve: Residence! Commercial _ Other Number of living units: Number of bedrooms 2, _ Character of soil to s depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ � ,, ._.�. Method of Disposal_.- Distance to nearest: Well Foundation Property Line LEACHING LINE P'-No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well •S f Foundation Property Line SEEPAGE PITS 11 Depth Size-- Number SUMPS Ll Distance to nearest: Well �'; Foundation— Property Line r r 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 r 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 must call for all required inspections. Complete drawing on reverse side. l "� 0 Signed Title:.��. Date: G FOR DEPARTMENT USE ONLY m Application Accepted by / Date �'-� r Are f Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: I / Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Servicei 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 '`r w FEE AMOUNT DUE AMOUNT REMITTEDFI RECEIVED BY DATE PERMtT'NO. INFO ♦ EH 13-24(REV,1/85) EH 84.26 O'{��. © 13 moi\ / p (}