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APPLICATION FOR PERidIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1 ENVIRONUWTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PRONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 REMIT ESPIRES 1 YEAR FROM DATE QED (Complete in Triplicate) Application is hereby wade to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address /Uja ,[ Cityagn Lot Size/Acreage Owner's Name ��a � Wav � Address M-0 22y ��'�'�- Phone Contractor �� 8Jd Address ' �a License No,-3z- 2_� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service Well Cl PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK'- _ SEWER-LINES--. "°""`— ` DISPOSAL FLD. PROP. LINE - FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ UNTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Weil Casing E ' [a Domestic/Private ❑ Gravel.Pack CJ Trac tR Type of Casing Specifications I'I Public Ia Other t1 Deh :; Aepth of Grout Seal Type of Grout * Depth at I I-trrivation _ .Approx. Depth 4 I Eastern Surface Seul Installed by Replair Work Done ❑ . Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I Mo septic system permitted-if public sewer is S available within 200 leet.j VN Installation will serve: 'Residence— Commercial_ Others ` a� GSE.✓ 0 Number of living units: .Number of badr 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 i Distance to nearest:-- Well Foundation Property Line c c L 4t3-42 9d_ZZM1_ LEAC6b LINE ❑ No. & Length of lines V Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line r SEEPAGE PITS 11 Depth Size Number SUMPS , tl 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, 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 mustI for all eq 'red ' poptions. Complete drawing on reverse sl E Signed —Title: Z Date: 2 FOR DEPARTMENT USE ONLY y� 2 Application Acceptedb . Date �`U_ �. Area T ! Pit or Grout inspection by Date Final Inspection Additional Comments: 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-- AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE t ERMI7'NO. INFO CASH ♦ EHr}3-241REV.I'm$) EH i4.2e