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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)465-'3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES _1 YEAR FROM DATE 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 coag liance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San F ��yyJoaquIn County Public Health Services. blob Address 3 ! I r 0 cityLot Size/Acreage KOwner's Name ' 'a[Jz�� 1 Address -e_>1_L A-7:1 Phone ContractorK �'�`'--a.Ci.J l Address � C.A�� CV7nse No.2��Phone 5 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C� 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 11 Industrial ❑ Open Bottom ❑ Manteca Dia. of Weil Excavation Dia. of Well Casing k 11 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 1—i Specifications 1 l Public Ci Other fl Delta Depth of Grout Seal i Type of Grout 1 i I Irrigation .Approx. Depth I I Eastern Surface Seal Insiailed`b}r—f Repair Work Done 0 Type of Pump H.P. State Work Done_ Well Destruction CI Well Diameter Sealing Material & Depth { Depth Filler Material S Depth Y l TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ! I DES TRUCTION (No'.septic system permitted if public sewer is NI Nvailabla within 200 feet.) k Installation will serve: Residence_ Commercial— Other Other Number of living units: Number of bedrooms --� Character of soil to a depth of 3 feet: Water table depth t SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Cl _.e---Method of Disposal- 4 Distance to nearest: Well Foundation ',Property Line ;r LEACHING LINE CI No. & Length of lines Total length/size ` FILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ f y I hereby certify that I have prepared this application and that the work will be done in accofdance 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, f shall employ persons subject to workman's compensa- tion law" , nia."cant mu all or req 're 1 s The app ec . ompiete drawing on reverse side, �y--� Signed Title: pate: _��-`I LJ _ i ., R DEPARTMENT USE ONLY � .� Application Accepted by Arl Date a ib_ Pit or Grout inspection by Date Final Inspection by at� r Additional Comments: Applicant - Return ail 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 CK 11 CASH RECEIVED eY DATE PERM17'NO, EH 13-24(REV.1/n51EH 14,26 / +.J cV '