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APPLICATION FOR PER1dIT �� (� • SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESCl�-t1� ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O SOX 2009, STOCKTON, CA 95201 PERiIIT 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 Rules and Regulations of San Joaquin County Public Health Services. j� Job Address �� &L—Ah ----------- City . Lot Size/Acreage Owner's Name V C+ Address Phone Contractor.6lJl�,- 1 :_ -Address � r License-No. 114x'-Phone- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well [3 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 C] Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I"I Public C] Other f l Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H P. _ _ __— _ _ State Work Done Well Destruction ❑ Well Diameter Sealing Material A Depth Depth Filler Material A Depth TYPE OF SEPTIC WORK; NEW INSTALLATION l I REPAIR/ADDITION TRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Res ante�C mmercial Other Number of living units: Number of bedrooms i Character of soil to a depth of-3 feet: _ _ Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ _ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 6L_-NV.-V Length of lines Total length/size FILTER BED C1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS A to nearest: Well Foundation As Property Line S 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 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- of California." 7Th$applicant call for allMedin ctio s. lete drawing on reverse ` Signe — Title: Date: r` DEPARTMENT USE ONLY r Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by �' Date Additional Comments: •• ID/ SGn, //D/ !� 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 INFO AMOUNTDUEAMOUNT REMITTED CASA RECEIVED BY DATE PERMITNO. r Eli 13-241REV. /x51 6o I�/� 01D �'+nis�l + If"� kA, EK 14.20 `f 1..7003 to `"� `"i