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APPLICATION 'FOR PERMIT2 E C � .. SAN JOAQUIN COUNTY PDBLIC HEALTH SERVICE ENVIRONMENTAL HEALTH DIVISION MAY 2 0 199! 1601 E. HAZELTON AVE. , PHONE (209)488-3 P O BOX 2009, STOCKTON, CA 95201 ��R[ONMENTAL HEALTH PERMIT/SERVICES PERMIT EXPIRES 1 YEAR FROM DAZE 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 c lance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Ne h Sery cee. Job Address Cj Lot Size/Acreage wn is Name Phone Cr nsY�Phone TYPE OF WELL/PUMP: NEW WELL t7l WELL REPLACEMENT - DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATiOk�El< SYSTEM REPAIR ❑ 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 L7 In ustnal ❑ Open Bottom ❑ Manteca Dia. of Welk Excavation Dia. of Well Casing stic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1'1 Public l:) Other n Delta Depth of Grout Seal Type of Grout I I Irrillation — App(ox. Dep l I Ea r Surface Seul Installed by ~ Repair Work Done 0 Type of-Rump P. -- --- ---- __State-Work.Dor Well Destruction O Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION I I INo septic system-permitted if public sewer is available within 200 feet.) installation will serve: Residence_ Commercial Other - - -r- _ '"' r y J Number of living units: Number of bedrooms v Character of soli to a depth of 3 feet: Water table depth � SEPTIC TANK D Type/Mfg, Capacity No. Cornpannients PKG. TREATMENT PLT. ❑ * Method of Disposal Distance to nearest: Well Foundation Property Line' LEACHING LINE ❑ No.A Length of lines Total Iengthihize-A FILTER BED E-t Distance to nearest: Well Foundation Pro_pe'Ay Line I SEEPAGE PITS 11 Depth Size Number- SUMPS Ll 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, an i 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 mannerias 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." ' Zed applica st call for a coons Coriiplete drawing an raver�ide. - Title: Date: R DEPARTMENT USE ONLY � Application Accepted by i Date Area � ^� Z Pit or Grout Inspection by Date Final Inspection by . _ Data _ l i Additional Comments, i 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 INFO AMOUNT DUE AMOUNT REMITTED CASH CK if RECEIVED BY DATE PERMIT'NO. . EH 13-24(REV.118 51 .IT 4f V F- EH i4-2a b