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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION S 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 REMIT EXPIRES I YEAR FROM DATE 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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services.. Job Address c, .e /'r"�fLI�1� � City � Lot Size/Acreage r T1�-1 Owner's Name ' `�as + 1 Address —,:—::PM ff _ _ _ _ Phone Contfaclo(WKL- O-- Cn&LS (Address O -% License No. a Phone qff-�_SLI TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well (3 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing [) Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'I Public [1 Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation —,Approx. Depth I I Eastern Surface Sedi installed by Repair Work Done 0 Type of Pump H.P.. State Work Done Weil Destruction 0 Well Diameter Sealing Material & Depth Depth Filler Material Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION l o septic system permitted if pubtic sewer is Vi available within 200 feet,) Installation will serve: Residence 9�Commercial_ Other Number of living units: -I— Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. 0 Type/Mfg Capacity No. Compartments r� PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ElDistance to nearest: Well 'Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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, 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 ca ,' les 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- tionla California.' The applican st cal fo all uir in amplete drawing on averse side. Signe Title; Date: — 'J 0— FOR DEPARTMENT USE ONLY } f Application Accepted by Date 71 Area Pit or Grout Inspection by Date Final Inspection by�, Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Rovironmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK 9 ASH RECEIVED BY DATE PERMIT'NO. . EN 13-24JAEV.lins)so 60 00 C (�� 11. 10- 91 EH 1610 r+ �] l ' ` hl-wul