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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. RAZELTON AVE. , PHONE (209)46$-3420 P 0 BOX 2009, STOCKTON, CA 95201 EXPIRES 1 YEAR FROM 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 �� City G Lot Size/Acreage Owner's Name 120 Address SS d o 'Phone ' -S Contractor / G Address /�p —License -Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well ❑. PUMP INSTALLATION ❑ SYSTEM REPAIR Cl OTHER ❑ Monitoring Well ❑ 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 L] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C:} Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public Cl Other n Delta Depth of Grout Seal Type of Grout I i Irrigation —,Approx. Depth I I Eastern ` Surface Seal Installed by09 Repair Work Done 0 Type of Pump H.P. State Work Done E Well Destruction ❑ Well Diameter Sealing Material & Depth 01) Depth Filler Material & Depth Ui TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRlADDITIO DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.l installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: 1>0 & 4j56 A-,, Water table depth l�b� SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ k, Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ty, No. & Length of lines ^7 �� Total length/size �� .�7— FILTER BED ❑ Distance to nearest: Well ' Foundation Property line SEEPAGE PITS I ) Depth Z J Size ``�+ �� 7 Number SUMPS l 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 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, 1 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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant musts call for all required'inspections. Complete drawing on reverse side. Signed Title: [1_r ------- ----- Date: ',, EOR DEPARTMENT USE ONLY Application Accepted by Date Area 112W Pit or Grout Inspection by Date Final Inspection by ata Additional Comments: Applicant - Return all copies to: Sari Joaquin County Public Health - Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, OA 95201•CK w CR INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. c� / `, V /Q . EH 13.24 IREV.I/a 5) 11q EH A•25 r f