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APPLICATION FOR PERMIT E � f SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HLAV � 0 _5420 P OBO% 200gSTOC�TONCA 95201 �U EXP RES 1 YEAR FROM DATE ED � ��"' GGG {Complete in Triplicate) ,,, Application is hereby made,to Sen Joaquin County for a permit to construct and/or install the work herein describe This application is made in compliance with San Joaquin County Ordinance No. 5w9 and 1862 and the Rules and Regulations of San Joaquin County Public Health services1/ � (1 City Lot Size/Acreage Job Address Address Phone G. Z3 Z Owner's Name Contractor Address License No&M .-. TYPE OF WELLIPUMP: NEW WELL 11WELL EPLACEMENT E3DESTRUCTION LI �t of Service fJell L1 OTHER ❑ Monitoring Well C7 PUMP INSTALLATION 0 SYSTEM REPAIR ❑ _- SEWER LINES �.�-r---- DISPOSAL FLD. DISTANCE TO NEAREST: SEPTIC TANK _� AGRICULTURE WELL OT PITS/SUMPS FOUNDATION �--- INTENDED USE TYPE OF WELL PROBLEM AREA CONST N SPECIFICATIONS pia. of Well Casing 0 Industrial ❑ Open Bottom _❑ Manteca �ia. of Well Excavation� �_ Specifications - ('I Domestic/Private Cl Gravel Pack ❑ Trac Type of Casing Type of I'I Public Cl Other Grout vita Depth of Grout Seal T.Approx. D pth I I Eastern Surface Seal Installed by I I Irrigation State Work Done Repair Work Done 0 Type of Pump H.P. t Sealingfkaterial f: Depth Well Destruction ❑ Well Diameter €. 1 t `' --� Depth Filler Material d =Depth t TYPE OF SEPTIC WOR NEW,INSTALLATION I I REPAIR/ADOITION-I I—DEST,RU TION available lpermitted 200 feet.) if public sewer is l �O Installation will-serV4—Residencel- Commercial— Other { Number of living units: Number of bedrooms ;. �,-.-�-„�_ { feet: Water table depth----T e Character of soil to a depot of�3 No. Compartments SEPTIC TANK. C3Type/Mfg Capacity��_ , " -'� ` Method of Disposal PKG. TREATMENT PLT.❑ 1 Distance to nearest: Well 4 Foundation t Property Line r f LEACHING LINE CI No. & Length of lines 4 Total length/size ` Property Line r FILTER BED C1 Distance to nearest: Well Foundation SEEPAGE PITS 11 Depth Size ! NuIm6er SUMPS LI Distance to nearest: Well Foundation Property Line k - 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 t rules and regulations of the San Joaquin County j Horne owner or licensed agent's signature cenifies the-following:-t-cartify-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,contfacting signature certifies the following: "I certify that in the pertofmance of the wofk for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." " > V f The applicant must all for all required inspe.ctt Compl a drawing on reverse side. f Date: Signed X de: F DEPARTMENT USE ONLY I C Date Lf. c) "` Area Applic ion Accepted by �. 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 I EEE CK RECEIVED BY DATE PERMIT'NO. INFO AMOUNT DUE AMOUNT REMITTED CASH } ' r . EH 43-24 1REV.118 5) EH 44.26 ..