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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 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSU (Complete in Triplicate) Application is hereby toads to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San JoaquinCo ty Ordinance No. 549 and 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. 7 DD ,r! ob Address City !�CTKQPLot Size/Acreage l Owner's Name r Address ��ND Phone /,J 0 Contractor Address �f 17u e I� r - _License No. Phone 8�`-� t/`+ T a Q TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIO9qOut of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing f Ll Domestic/Private ❑ Gravel Pack Ll Tracy Type of Casing Specifications Fl Public 1-1 Other ❑ Delta ' Depth of Grout Seal Type of Grout I I Irrigation — Approx. Depth I I Eastern x Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. c-" State Work Done n Well Destruction ❑ Well Diameter Sealing Material & Depth �✓ Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDI - N t I DESTRUCTIO I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence T Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg C ity No. Compartments PKG. TREATMENT PLT. D Method of Disposal �7 Distance to nearest: Well Foun ation Property Line LEACHING LINE ❑ No. & Length of lines Z Total length/size FILTER BED CI Distance to nearest. Well Foundation Property Line SEEPAGE PITS 11 Depth Size Nuar SUMPS Ll Distance to nearest: Well Foundation roperty 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, 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: "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." j The appli ust rail for al squired i "ctions. Complete drawing on reverse side. KA .] Signed X� _ �-� Title: Date: v DEPARTMENT USE ONLY Application Accepted by S1�c�_..:.1Llh..:. , y �sWit,_ �.n Date Area� — Pit or Grout Inspection by Dat 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 CK RECEIVED BY DATE PERMIT'N0. F INFO CASH . EH 13.241REV.Iih5) t� O�Q EH;