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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 P 0 BOX 2009, STOCKTON, CA 95201 EXPIRES 1 YEAR FRPM DA19 15PUED (Complete in Triplicate) Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 5119 and 1862 and the Rules and Regulations of San Joaquin County Public Healyh Service ?-&/i. Job Addrass City Lot Size/Acreage Owner's Name �— Address � � �� - Phone C.N ContractorAddr s l License No. Ph n E OF WELL/PUMP: NEW WELL ❑ WELL REPLA_,915MENT ❑ DESTRUCTION ❑ Out of Service Well ❑ S PUMP INSTALLATION 0 SYSI;VA REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK EWER LINES DISPOSAL FLD. PROP. LINE �+\ FOUNDATION A RICULTU WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM E CONSTRUCTION SPECIFICATIONS i7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C.] Domestic/Private El Gravel Pack 0 Tracy Type of Casing Specifications I`l Public Cl Other n Del epth of Grout Seal Type of Grout d I I Irrigation _.Approx. Depth I I stern rface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Mater 1 & Depth Depth Filler Material Depth TYPE OF SEPTIC WORK: NEW IN$TAFa1TION I I REPAIRlADDITION I f DESTRUCTION] iNo septic system permitted if public sewer is available within 200 leaLl Installation will serve: Residence_ Commercial__.. Other y Number of living units: Number of bedrooms ^� s ' Character of soil to a depth of 3 fest: Water table dipth 4- SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ` 1 PKG. TREATMENT PLT. ❑ Method of Disposal ,(V` Distance to nearest: Well Foundation Property Line N LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation 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, 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 signatur 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 compen> tion laws of ahfornla." The applic nt call for all requir d ins ions. Complete drawing on revere side. c� Signed ` Title: __ .n a� �t�✓�- Date: d� 0 EPARTMENT USE ONLY Applicatio A sp d Date Area Pit or Ciro t ns Clio by Date Final Inspection by Date Additions Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2909, Stockton, CA 95201 FEE INFO AMOUNT DU MOUNT REMITTED CASCK A RECEIVED BY DATE PERMIT'NO, a EH 13-21 1fiEv.1 N 51 �^f7 /7 C u t./ Y ��j 9 p g c,-a2.9 EH 71-2e 4 !©� e 1 I