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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISIONS 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 J pgMIT EXPIRES 1 YEAR FROM DATE IS9UI0 (Complete in Triplicate) Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This applicatioi2'is made in Compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Servicess.. li Job Address ,A/- A2 '� ` City L 0a -- Lot Size/Acreage /tCl7t Owner's Name Address Phone ..,_, �� Contractor Address CLeA License Notes 7i Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well Gl PUMP-INSTALLATION 17 SYSTEM REPAIR ❑ OTHER C] Monitoring Well "`E] DISTANCE TO NEAREST: SEPTIC TANK" tea_ SEWER LINES i "�` DISPOSAL FLD. PROP. LINE T- FOUNDATION "` AGRICULTURE WELL OTHER WELL PITS/SUMPS { INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS1 n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing z (� ❑ Domestic IPrivate' '❑ Grave! Pack ❑ Tracy Type of Casing Specifications k Il Public LI Other 1 11 Delta Depth of Grout Seal Type of Grout I I Irrioation _.Approu: Depth I I Eastern Surface Seal Installed by f Repair Work Done ❑ Type of Pump H.P. State Work Dane _ r— o Well Destruction ❑ Well Diameter Sealing Material & Depth Depth I Filler Material & Depth TYPEOF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION. DESTRUCTION l IANo septic system permitted if public sewer is i available within 200 feet.I Installation will serve: 'Residence Commercial ✓ OtherE, Number of living units: S Number of 4edtoom. -01 .STZK.4 r Character of soil to a depth of 3 feet' Water table depth t SEPTIC TANK E1 Type/Mfgli—Lad ap city No. Compartments PKG. TREATMENT PLT. ❑ ' Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE U No. & Length of lines Total length/size , FILTER BED Ct Distancetonearest: Well Foundation Property Line t SEEPAGE PITS 11 Depth �2 Size Number ! v r SUMPS tq—Distance�to nearest: + Wel! 160de Foundation 0 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: "I certify that in the performance of the work for which this permit is issued, I shall not h employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature { ^4 cartifies 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." I The appli ant must call for all requ"ed i spections. Complete drawing on reverse side. e JJ 4G Signed Title: uJirlt Date: !l 7� FOR DEP RTMENT USE ONLY Application Accepted by, date Area Pit or Grout Inspection by n Date ' Final Inspection by u - Data�G Additional Comments: r Applicant - Return all copies to: San Joaquin County Public Health f Services, Environmental Health Permit/Services ` 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0. INFO ) /��7 . EH13.24(REV.rin51 �G / Liv �'J� 6• "�� EH 14-A