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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION I 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 f P O BOX 2009, STOCKTON, CA 95201 P—MIT EXPIRES 1 YEAR FROM DATE ISSUED (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 RuleB and Regulations of San Joaquin County Public Health Services. Job Addrest:� r) City Lot Size/Acreage Owner's Name., — Address Phone Contractor 11 Address _ � F t ^�License No. 3 i ;W Phone 39�63 7� { TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT M- DESTRUCTION D Out of Service Well L7 # PUMP,INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK ' i SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION 'AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL 'PROBLEM AREA CONSTRUCTION SPECIFICATIONS 171 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 17 Domestic/Private ❑ Gravel Pack ❑ Tracy! Type of Casing Specifications I') Public I-i Other n Delta j Depth of Grout Seal Type of Grout ,-I l Irritj l on �, I� —..Approx. Depth I I Eastern Surface Saul Installed by Q "'Repair Work_Done U Type of Pump H.P. State Work Done_ Well Destruction ❑ �WeII Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: t NEW INSTALLATION I I REPAIR/ADDITfON 14- DESTRUCTION l I (No septic system permitted if public sewer is I available within 200 feet.) Installation will serve:€Residence's 7 Commercial_."10Other Number of living units: ,=.L_ Number ofedroo s 2-- r Character of soil to a depth of 3 feet: i492--- Water table depth Q 9 SEPTIC TANK. llr�rDii!ance /0 Tpe/Mfg �� _ J Capacity` No. Compartments Z PKG. TREATMENT PLT. ❑ "� " Method of Disposal Foundation Property Line f LEACHING LINE Cl No! & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS [ 11 Depth Size Number _ SUMPS L'=r-Distance to nearest: Well- , Foundation _� r +_ Property Lined .� DISPOSAL PONDS ❑ r I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stats laws, and rules and regulations of the San Joaquin County r ter° I Home owner or licensed agent'a 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 Cafifornia:`' 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."i # I !I I t 1 t I I { The applicant must call forrall req ' ed=i pections.-Complete--drawing on reverse side, Signed r Title: AeA - Date: :s _ DEPARTMENT USE ONLY �lltetl0[1�CCeptB� b ��_—Gr/ Y ""�T� !iDate_ Area t; A', ar Grout Inspection by Dat -� Final Inspection by Date j_�r "� r Additional Comments:. J '� Applicant - Return.al14Lcopies to: San Joaquin County Public Health ` JServices, Environmental Health Permit/Services , t 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. EH.4.26 rv.1/" Y� I f 51 an 1�1