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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 %P RES 1 YEAR FR M DA ED (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. Job Address CityLot Size/Acreage _ Owner's Name` 1TlJ-t% - l �sCrr Address- j "'s: - Phone- Contractor �. / y/ `Address /=ditQ dt�License No.��•Phone• TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 1-7 DESTRUCTION ❑ Out of Service Well 0 j 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 f� Industrial C1 Open Bottom C) Manteca Dia. of Well Excavation } Dia. of Wel! Casing Ca Domestic/Private ❑ Gravel Pack ❑ Tragy,_ _- _' Type of Casing Specifications ('1 Public 1-1 Other. fl Delta Depth of Grout Seal Type of Grout I I lrriga.lion _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done- L] Type of Pump I H.P. State Work Done T Welt Destruction 0 Well Diameter Sealing Material & Depth 1 Depth a Filler Material&-Depth .-- TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIRYADbITION DESTRUCTION I ) iNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence.,.,Commercial_ Other ` Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depfh. I SEPTIC TANK 0 Type/Mfg Capacity Noe-do-partments PKG. TREATMENT PLT. 0 1 _. r"'Method of Disposal ' y Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of tines % Total length/size r FILTER BED ❑ Distance to nearest. -Well--�-�Foundation 50 Property Line � SEEPAGE PITS [ I Depth Size Number 1 SUMPS i Ll—Distance-to nearest: .. Well Foundation Property Line - DISPOSAL PONDS Cl 1.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 ules and regulptions of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that in the performance of th6 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 eertity 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 all r quire "nspecV ns. Complete drawing on reverse side. Signed c Title: Data: FOR DEPARTMENT USE ONLY Application Accepted by Date � Area Pit or Grout Inspection by Date Final Inspection b _Si�_ Date6r2!0`_7 j 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 INFO AMOUNT DUE AMOUNT REMITTED CKCASH RECEIVED BY DATE PERMIT'NO. • + EH 11.E IRiV.1/851 S {}�, Do