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APPLICATION FOR PERMIT y • ht. SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION �tj1� jyvnvn. 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 -� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED W r` (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, 0 inane No. 54 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. ? ` �4 t Y11,0b Address City Lot Size/Acreage wner's Name Address r aadf�Lt, ' Phone \,ContractorAddress � License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 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 n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I"1 Public 1-1 Other n Delta Depth of Grout Seal Type of Grout ��-- I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by T Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth 1 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION X(No septic system permitted if public sewer is vailable within 200 feet.) �f Installation will serve: Residence_ Commercial_ Other r7 Number of living units: Number of bedrooms t" 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 Cl No. & Length of lines Total length/size FILTER BED CI Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O _ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinanc98V4 ete Ia9+s,,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- tion laws of California." The applicant must call for al ui ed insPections. Complete drawing on reverse side. Signed Title:= � �-�� Date: FO EPARTMENT USE ONLY q M� Application Accepted by al Date IAre 1 hyq4d uI Pit or Grout Inspection by Date Final Inspection by e� Additional Comments: Applicant - Return all copies to: Sen Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO _*MOUNT DUE AMOUNT REMITTED CK I CASH RECEIVED BY DATE PPERMI`T'NO. . EH 13.21 IPEV.1/n 51 c1� �� C1( (1 EH";1.2e tVVf