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APPLICATION FOR PERMIT i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 %P RES 1 YEAR R DATE ISSUIP"IT (Complete in Triplicate) I Application is hereby made.toSan 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 oro .. City Lot Size/Acreage Owner's Name ` Address - Phone 'b. • Contractor Address 444License No. / Phone �z TYPE OF W LIP M NEW WELL El WELL REPLACEMENT (-1 DEST UCTION ❑ out of Service Well L)PUMP INSTALLATION ❑ SYSTEM REPAIR C7 OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LI NE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C_1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack. ❑ Tracy Type of Casing Specifications I•I Public Cl Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation _.Approxi Depth I I Eastern Surface Seal Installed by � ' .. Repair Work Done U Type of Pum'p H.P. State Work Done I l Well Destruction E) Well Diameter. Sealing material & Depth Depth Filler Materi & Depths - TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITIONDESTRUCTION I I (No septic system permitted if public sewer is available within 200 feot.i ^ � i Installation will serve:.- Residence—__ Commercial then Number of living units: _./. Numher of bedrooms ' Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK u ❑ Type/Mfg Capacity_ — No. Compartments PKG. TREATMENT PLT.❑ wi V r Method at Dispo�al y Distance," Barest: ,- %Wall Foundation - -- Property Line LEACHING LINE ❑ No. & Length of lines — Total length/size19- FILTER BED n Distance"to neatest:% .j Well Ute-- Foundation s Property Line i SEEPAGE PITS 11 Depth --Size TO 3 iii �r1 Number t .!) SUMPS LI Distance to nearest: Well 40 Foundation — Property Line DISPOSAL PONDS ❑ t i 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 employ any person in such manner as to`become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature cartifiss the following: "1 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 must c forII;,Irlln"ctions. amplete drawing an reverse side.SignedTitle: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area -7 J/--- � Date Final Inspection b Date /I 1.:�'or Grout inspection by Additional Comments: ,.t Applicant - Return all copies to: San Joaquin County Public Health i Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED I CA5H RECEIVED BY DATE PERMIT'NO. ,\ INFO 1 .,-tea 1 �J . EH 13-24IREV.1 51 L� ano �� t H 14,26 'o r