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r APPLICATIOR FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 3.601 E. HAZELTON AVE. , PHONE (209)46$--3420 P 0 BOX 2009, STOCKTON, CA 95203. � EXPIRES 3. YEAR FROM DATE .�► �p�e (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 dinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address I �- r City hot Size/Acreage Owner's Name ��A, Address 10 K !�� t-_. 1 �0# K)5_ e Contractor i� t rF.r: Address, � �r��r1G Y_ _ —_ License.No.� �Phone —Ielallr TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION 0 SYSTEM REPAIR ��`A OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES J DISPOSAL FLD. PROP. LINE FOUNDATION \AGRICULTURE'WELO OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL -PROBLEM AREA" CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca pia. of Well Excavation Dia. of Well Casing 17.1 Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications VI Public C1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation .4Approx. Depth # Eastern Surface Seal Installed by Repair Work Done ,'fid Type of Pump H.P. r =t'� State Work Done Well Destruction ❑ Well Diameter Sealing Material T& Depth Depth Filler Material b Aepth , TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I i DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) f Installation will serve: Residence— Commercial Other i Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ 'Type/Mfg Capacity No. Compartments i PKG. TREATMENT PLT. ❑ :. Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl i.No. & Length of lines !. Total length/size FILTER BED ❑ '.Distance to nearest: Well ` Foundation: t- Property Line --*- SEEPAGE PITS 11 -Depth Size Number _- SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 'i ' 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 thieper6l is i e_d,'I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring o►.sub=aontracting signature q certifies the following: "I certify that in the performance of the work for which this permit is issued,'I'shali employ persdns subject to'workman's compensa- tion laws of California." t The apprcant mu call for all required ins 09ons. mpl drawing on rse side. Signed Title:, jl _ ^* Date. j FOR DEPARTMENT USE ONLY �n 7' 3 ice, t- Application Accepted by I Date d Area ' Pit or Grout Inspection by . Date Final Inspection by Date v Additional Comments: CApplicant - Return all copies to: San Joaquin County Public Health I Services, Environmental Health Permit/Services ham(\ 1601 E. Hazelton Ave.. P 0 Bax 2009, Stockton, CA 95201 ' FEE I INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERM17'NO. . EH 13-24IFIEV.i/a5) -7 EN'14.20 - t