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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 `w P 0 BOX 2009, STOCKTON, CA 95201 [7 PERMIT EXPIRES ,I , YEAR FROM 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. 549 and 1$62 and the Rules and Regulations of San Joaquin County Public Health Services.r )fie Job Address ZS /'�/ e D�L I� ��+ ___ City Lot Size/Acreage S Owner's Name Address Phone f� Contractor , Address .0 ice, + License No.3AWV6 Phone 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 FOUND AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBL CONSTRUCTION SPECIFICATIONS F] Industrial ❑ Open Bottom ❑ Manteca i Well Excavation Dia. of Well Casing �l Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casa 5peci(ications----- I') Public i-1 Other 11 Delta Depth of Grout Seal Type of Grout I # Irrigation �.Approx. Depth 1 I Eastern Surface Seai Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material 6 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTI N INo septic system permitted if public sewer is ` vailable within 200 feet.) installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms t Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ .Type/Mfg Capacity--------- No. Compartments PKG. TREATMENT PIT, ❑ Method of Disposal Distance to nearest: Weil Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line ' SEEPAGE PITS t I 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-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 mu calf for all require inspections. Complete drawing on reverse side Signed Title: Date- 11 DEPARTMENT USE ONLY Application Accepted by C.�� 1M1-61 &IM\ y�, Date ck Area 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 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CA K RECEIVED BY DATE PERMIVNO. + EH 13-24 IREV.r/ns p oo 4 EH 4-2e