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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 TgRMIT EXPIRES- 1 YEAR FROM DAIE 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 99 City Lot Size/Acreage/0 p� �f 6 d Owner's Name �1:7�D/�.f1.ln�> Address Phone �� ContractorajjAddresscense NoI Phone M TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well 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 Dia. of Well Casing [I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F] Public Ia Other n Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I Ir REPAIR/ADOITION i I DESTRUCTION ( 1 iNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other { Number of living units: ---F— INumber of bedrooms J_- -- Character of soil to a depth of 3 feet: 9 Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well ,62 Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Ll Distance to nearest: Well/9 f� Foundation _ L Property Line SEEPAGE PITS 11 Depth ' Size Number Ll Distance to nearest: Well 102 _ Foundations Property Line DISP05AL 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, andT 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 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 applicant st call f0i r quire s clions. Compl a ing on rave si e. Signed X Title: Date: R PARTMFNT USE ONLY Application Accepted by ADatT 5 `~ 1�?_ Area Pit or Grout inspection by Date Final Inspect i n by > � Dales ? Additional Comments: rrs � `s l to z 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 AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT'NO. INFO 99 4 /jCASH . EH 13-24[REV.I/a 5) O p� f r !T/ O 190— /16J EH 14.26 ��••fff�n��