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APPLICATION FOR PERMIT T SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES PAYANENT ENVIRONMENTAL HEALTH DIVISION RECJel 1601 E. HAZELTON AVE. , PHONE (209)468--3420 VIED P-0 BOR 2009, STOCKTON, CA 95201 f SANJOAQUIN CQUNTY P IT EXPIRES- f -YEAR- FRQY.PATE ISSUED PURL16 HEALTH SERVICES (Complete in Triplicate) ENVIRONMENTAL-HEALTHD1Vl5lON 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 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address u^'�� City`/L� Lot Size/Acreage Owner's Name !�_ 102 Addressl Phone ad Contractor /7 _ Addres G icense flo.�d �© Phone `- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION C] SYSTEM REPAIR ❑ OTHER Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial j. ,❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private r fC] Gravel Pack ❑ Tracy Type of Casing Specifications VI Public f (:7 Other fl Delta Depth of Grout Seal Type of Grout ( � I I tfrigalion r .Approx. De h I I Eastern Surface Seal Installed by v _ .QQ a Repair Work Done : Type of Pump �_ H.P. ,. State Work Dore r(� Well Destruction CT' Wall Diameter ` , ' Sealing Material 6 Depth V r I Depth Filler Material 6 Depth e-0 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION'1 1 INo septic system permitted if public sewer is ` available within 200 feet.) Installation will server Residence__;_ Commercial Other, ' Number of living units:. "_Number of bedfooms Character of &oil to a'depth of 3 feet: Water table depth SEPTIC TANK. r: ❑ .-Type/Mfg Capacity- No. Compartments , PKG. TREATMENT PLT. D^ ,.r ,. , r Method of Disposal Distance to nearest: Well ' ~ Foundation Property Line 1 ; i LEACHING LINE L1 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line i 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 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: "I certify thayin the performance of the work for which this permit is issued,i shall employ persons subject to workman's compensa- tion laws of California." t The applicant must call t ll required inspections. Complete drawing on re se side. G; Signed x_ c ' Titls _ Date: FOR DE RTMENT USE ONLY Application Accepted byr Date Area t Pit or Grout Inspection by Date Final Inspection by Date�� Additional Comments.- Applicant omments:Applicant - Return in copies to., San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P O Box 2009, Stockton, CA 95201 FEE INFO/ AMOUNT DUE AMOUNT(REEMIITTED C SH 11 RECEIVED BY �[ tDATE�/S1 PERMITNO. . EH fy24IREV.iinS! /: _ T, `l9L 1-n-773 ~ -7 3 EH 1111.26 !