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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 0 BOX 2009, STOCKTON, CA 98201 PEWIT MIRES 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 vork herein described. This application is made in compliance with'San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address e ro /C'dc City Lot Size/Ac eage /4Q Owner's Name 9 Addressto Z-Phone Contractor � Addressa�7- 1elUvl �d rt'P a License No Phone OF TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIRX 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 C] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation r pia. of Well Casing Fl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing A. Specifications F] Public 1.1 Other n Delta Depth of Grout Seal Type of Grout X Irrigation _ Approx. Dept 1 1 Eastern Surface Seal installed.by Repair Work.Doi4 Type of Pump H.P. +* ',State Work Done o- i Well Destruction ❑ Well Diameter Sealing Material & Depth'•.. ' t Depth 4n Filler Material & Depth TYPE OF SEPTIC'WORK; NEW INSTALLATION I I REPAIR/ADDITION I f-DESTRUCTION 1 1 (NO Septic stem Perm if Q�_ P Y P public sewer is available within 200 feet.) Installation will serve: Residence— Commercial other Number of'livirtg units: Number of bedrooms Character of soil to a depth of 3 feet: J Water table deptk A• i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments'-*-'- . PKG. TREATMENT PLT. Cl .I Method of Disposal Distance to nearest: Well t Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED IJ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I` Dapth +Y i Size _ Number SUMPS LI 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 r 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 cartifies the following: "I certify that in the performance of the work for whi6h this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applica st call for all required ' ction omplete drawing on rse side. Signed X_�/-C; Title: Date: " FOR DEPARTMENT USE ONLY Application Accepted by .Date v Area Pit or Grout Inspection by Date—.Final Inspection by Date 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 CI{ INFO CASH RECEIVED BY DATE PERMIT'NO. E EH t3-24{REV.tin 51J"(N �^ EH 44.2:6 151v—^� I_J1