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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)488--3420 P O BOX 2009, STOCKTON, CA 95201 RES 1 YEAR FRQM DATE ISSUED (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. 5119 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 7o 56 r— !Ej—�� City��'it_I Lot Size/Acreage Owner's Name Address Phone Contractor Address License fQge �Phone T TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out 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 _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing CI Domestic/Private ❑ Gravel Pack C1 Tracy Type of Casing Specifications Fl Public l-1 Other Cl Delta Depth of Grout Seal Type of Grout I i Irrigalion _.,Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth O TYPE OF SEPTIC WORK: NEW INSTALLATION 13 REPAIR/ADDITION DESTRUCTION ( I lNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Z Commercial_ Other Number of living units: / Number of bedrooms 3 Character of soil to a depth of 3 feet: _... r V Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines 92 Total length/size 17 SQ FILTER BED Distance to nearest: Well � Foundation 145f Property Line 1SD5F�� SEEPAGE PITS 11 Depth Size _ Number -_ SUMPS LI 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, 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•convacting 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 *t The applicant must call for I requ red inspeclions, Complete drawing on reverse side. Signed XTitle:- Date: ONLY Application Accepted by Date G Area 001 /0 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 . j 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 IEEE AMOUNT DUE_ x AMOUNT REMITTED CASH _ RECEIVED BY DATE PERMIT NO. r .. .,.,+,. t. .. ... + EH t3-241AEV.VAN 51 n EH 14.25 ' �lZl to all ti