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APPLICATION FOR PERMIT , SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZEL-TON AVE. , PHONE (209)468-3420 P A" �T G�� P O BOX 2009, STOCKTON, CA 95201 R>E G F 1 V E D ; WIRES 1- ..YEAR FROM D ED DEG 141990 1 (Complete in Triplicate) Application is hereby made,to San Joaquin County for a permit to construct and/or install th� e r#ACd .�htis application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the pC5 of San Joaquin County Public Health Services. Job Address 3 r Cit Lot Size/Acreage Owner's Name A, � Phone fi Contractor f - Address y � �License No�Z/ 2L_ --_ Phone TYPE OF WELLIPUMP: NEW WELL D WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS y INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS A Industrial ❑ Open Bottom 11Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private y' ❑ Gravel.Pack L] Tracy Type of Casing Specifications 1 I'1 Publicr*�.i-1 Other n Delta Depth of Grout Seal Type of Grout I i Irrigation � ....,_„Approx, Depth I 1 Eastern ,L Surface Seal Installed by Repair Work Done A 4. - eu -Type of Pum ��v H.P.Y7 _ State Work Da e Well Destruction ❑ Well Diameter Sealing Material &-Depth - 42 Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION f I REPAIR/ADDITION I I DESTRUCTION i I�INo septic system permitted if public sewer is 3 ^'o L ava ilableL within 200 feet.I Installation will serve: Residence— Commercial_ Other (�I Number of living units: Number,of bedrooms i V Character of soil to a depth of 3 feet: a ”' _ W Water table depth SEPTIC TANK-, ❑ Type/Mfg Capacity No. Compartments v PKG. TREATMENT PLT. ❑ 4. Method of Disposal rr Distance to nearest: Well Foundation Property Line Tb .6 , t r . LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Ll Distance to nearest: Well Foundation Property Line t SEEPAGE PITS 11 Depth Size Number -SUMPS L1 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 i 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." The applicant ust call for It ired inspections, Complete drawing on re se side. Signed X ��a�-- _._ Title: Date: f Q FOR DEPARTMENT USE ONLY -7 Application Accepted by Date // Area Pit or Grout Inspection by Date }° Final Inspection byloaii2 Datt)/ Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health I` 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 PERMITNO. INFO },�} pCASH . EH13-241REV.rrnsi !°f�t& EH 11.20