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cc. APPLICATION FOR PERMIT ' r i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 -f EXPIRES 1 YEAR FROM DAT ED (Complete in Triplicate) r ' Application is hereby made 11to San Joaquin County for a permit to construct and/or install the work herein described,. This A application is made in oo4liance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services, II Job Address '/ r Ip Cityar- mt Size/Acreage Owner's Name Address C 6 �_ Phone�3ca. Contractor Address �' ��, _ License No. Phone TYPE OF WELL/PUMP: �� NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Weil Ll PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well [] 1i. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOII40ATION 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 ,}- [D Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Il Public FI Other n Delta Depth of Grout Seal Type of Grout vv + I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by t Repair Work Done L7 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth DepthFiller Material & Depth TYPE OF SEPTIC WORK; NEW I NSTALLATIO l REPAIR/ADDITION f I DESTRUCTION I I INo septic system permitted it public sewer is t i Ii available within 200 feet.) i Installation will serve: Residence_ Commercial____.. Other t Number of living units: ,I Number of bedrooms-It_ i Character of soil to a depth of 3 feet: �I Water table depth n SEPTIC TANK. Typke/Mig Capacity No. Compartments PKG. TREATMENT PLT. ❑ I� Method of Disposal Distance to nearest: Well t. Foundation Property Line it LEACHING LINE ❑ No.ii& Length of lines Total length/size FtLTER BED n Distance to nearest. Well Foundation Property Line it SEEPAGE PITS IJ Depth Size T Number SUMPS D Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I EE 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 i 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 j employ any person in such manner'as td become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certif that' the perfo of th 6,kor which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of Californle," The applicant must c or all spa s. C d ing on reverse side. - i Signed ttie: Date: i! FO PART T USE ONLY Application Accepted b Date Area i Pit or Grout Inspection by I� Date Final Inspection b R y Date 1 Additional Comments: it Applicant - Return all copies to: San Joaquin County Public Health J� Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERM17'ND. INFO + (`(�� CASH ,�/�1j/�� TE q . . EH13-24fREV.1iHsl 1 `-"' �Q O 1 r r QY1v' 1I � 'V EH i42a Illi �It