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APPLICATION FOR PERMIT S SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION N o-� 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOR 2009, STOCKTON, CA 95201 lx�D REMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 0,,ac W . Application is hereby made to San Joaquin County for a permit to construct and/or inetall 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 Services. Job Address alLp City Lot Size/Acreage Owner's Name CAddress � � Phone 469_ J Conlractor S Address-_ I i t C. License No,---4 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well L7 PUMP INSTALLATION ❑ SYSTEM REPAIR C1 OTHER ❑ Monitoring Well L7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD 4 PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial L7 Open Bottom C1 Manteca Dia. of Well Excavation pia. of Well Casing Cl Domestic/Private -❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'l Public fa Other 11 Delta Depth of Grout Seal Type of Grout I I trriUation _..Approx. Depth 13 Eastern Surface Seal Installed by r� Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth i TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR1ADDITtON I f DESTRUCTION INo septic system permitted it public sewer is available within 200 feat.l ' Installation will serve: Residence— Commercial— Other ' Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water labia depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ �y Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Tota! length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line 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: "! 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, I shall employ persons subject to workman's compensa- tion laws of California." The applic must call for II required inspections. Complete drawing on reverse side. Title: W Signed ��e��_ _. Date: F DEPARTMENT USE ONLY Application Accepted by — ' ,.._,_.. Date � Area r Pit or Grout inspection by Date Final Inspection by ^ Date t Additions! Comments: N Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNTREMITTED CK RECEIVED BY DATE PERMIT'N0. INFO CASH . EH132�1IREV.vin5) .vii �. 47-a c. 67 �B�o iio_j14 .