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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 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I - (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. c Job Address t ,City Lot Size/Acreage Owner's Name A,,, _ Address � Phone - License No l oA �Wt Phone Contractor �r '' Address8 f T TYPE OF WELL>PUMP: NEW WELL'x❑ ya t rWELL REPLACEMENT C] DESTRUCTION C] Out of Service Well [3 ti «ry PUMP INSTALLATION- ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK 'L SEWER LINES 'DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL 'OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL' PROBLEM AREA CONSTRUCTION SPECIFICATIONS C}.Industrial ~❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing [-7 Domestic/Private -0- Gravel Pack ; ❑ Tracy y Type of Casing Specifications ['I Public , FI Other �! ,? n Delta `; Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump? f H.P. ` State Work Done_ E Well Destruction O Well Diameter Sealing Material & Depth 1 ` Depth 3 Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I ' DESTRUCTION I I lNo septic system permitted if public sewer is ,,.. 1 1 . available within 200 feet.) Installation will serve: Residence `'3 Commercial_ Other i Nurnber..of living units: ._ Numbertof bedrooms 4 ti _:4: -��I .�.. Character of-soil to a depth:6f Xfeet:- -per _ "' � Water table depth SEPTIC TANKI ❑ Type/Mfg '_- r`44 i Cor. Capacity No. Compartments PKG. TREATMENT PLT. ❑ ,. ? Method of Disposal ��_� i, s 7 d e Distance to nearest:'� Well FoundationO F �Property Line s LEACHING LINE , 'No. & Length of lines a F Total length/size # FILTER BED n t Distance to Weare"st: Well A✓5 Foundation �� Property Line N ? SEEPAGE PIT l I Depth F Sized'c Numbers SUMPS s P" Distance to nearest: Well x Foundations. '• Property Line t DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the.wbrk will be done in accordance with San Joaquin county ordinances, state laws, and"*', rules and regulations of ithe San Joaquin County 'I-_•°' Homeowner 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 mariner 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.Perf6irn ince of the work for which this permit is issued, f shall employ persons subject to workman's compensa-t% ' s tion laws of California.'` ! 4 1 The applicant must call for all aqui ed inspections. Complete drawing on reverse`side. Signed Title: ��r.•A _ Date: /.X- FOR DE RTMENT USE ONLY L ; r Application Accepted Date ea Pit or Grout Inspection by Date Final Inspection Date I Additional Comments: Y Applicant - Return rill copies to; �San Joaquin County Public Health q. . Services, Environmental Health Permit/Services s # 1601 E. Hazelton Ave., F 0 Box 2009, Stockton, CA 95201 _...; CIC - - --� INFO AMOUNT DUE,,,,_ .� AMOUNT-REMITTED —CNSBY-.- ---, DATE— —PERMt-TW0--1 1: EN 13.24(REV.i/n5i .©C'3 Eri��•�.., l Wim]