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APPLICATION FOR PERMIT v/ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 P 0 BOX 2009, STOCKTON, CA 95201 EXPIRES 1 YEAR FROM PATE 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 1662 and the Rules and Regulations of San Joaquin County Public Health Services. �1 / Job Address —? Q City, 6CA Lot Size/Acreage hp� Ov_ef s Name f Address 1 �'f Phone Contracloll lu+f]P Address .953 4, L incorn7 il� L ense No..��CJb7 �Phone�S 20y� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIWJP3 Out of Service Well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C]\ Monitoring Well L7 Q 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 C-} industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing J 1.1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public 17 Other n Delta Depth of Grout Seal Type of Grout I I Inigation .._.Approx. Depth I i Eastern Surface Seal Installed by Repair Work Done U /Type of Pump H.P. tate Wolk Done_ Well Destruction 0/ Well Diameter -- Sealing Material & Depth Depth_-_ -- jar Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I f DESTRUCTION I i (No septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence_ 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 Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size \ FILTER BED ❑ Distance to nearest: Well Foundation_ Property Line 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'a 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 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 applic nt t call all squired inspeetio Complete drawing on reverse side, p p Signed Title: Date: Is DE RTfMENT USE ONLY Application Accepted by Date - Area Pit or Grout inspection by Date Final Inspection by Date Z Additional Comments: ih( 11 . ~ Applicant - Return all copies to: San Joaquin County Pu Iic Health - �U Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 - INFO AMOUNT DUE AMOUNT REMITTED CASA RECEIVED BY FEE DATE PERMIT NO. + EH 13-24 IqEV,i i H 5) A.:�-24 t