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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 O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSVID .r (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 Service ��* 1 Job Address City Lot Size/Acreage _ j Owner's Name Address Phone Contractor �A�icense Address Noy Phone /0 TYPE OF WELL PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well U 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 F_-] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing F_] Domestic/Private ❑ Gravel Pack L7 Tracy Type of Casing - Specifications I'I Public Cl Other n Delta Depth of Grout Seal Type of Grout I i Irrivation .Approx, Depth . I 1 Eastern Surface Sedl Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth / Depth Filler Material b Depth IL1 I TYPE OF SEPTIC WORK: NEW INSTALLATION (ir REPAIR/ADDITION I ] DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet,) i Installation will serve: Residence t Commercial— Other _ Number of living units: _L_ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/MfgCapacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal ['} Distance to nearest: Well Foundation B Property LineP ;c LEACHING LINE ❑ No. & Length of lines 5 ~ Total length/size FILTER BED 0—Distance to nearest: Well Foundations_ Property Line _X12 Z-71 SEEPAGE PITS I I Depth X IM(Aze Number SUMPS 0 Distance to nearest: Well/ 0 Foundation 19 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 cenifies 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: "l 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 must call for all rf�uifed inspection Complete drawing on reverse side. J71 fo Signed X� �C.IV Title: Date: j FO EPARTMENT USE ONLY y� Application Accepted by t Date 1� .. ._ Area Pit or Grout Inspection by Date Final Inspection bM�-y- Date Additional Comments: S s ,-- --�a 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 CK RECEIVED BY DATE PERMIT N0. INFO CASH EH 13-24 IAEV,i H 51 EH tf-2e