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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. ,' PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUNP (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 1862 and the Rules and Regulations of San Joaquin County Public Health Sery)1154- Job Address City Lot Size/Acreage Owner's Name �1 -- Address �j � f d/ ` Phone Contractordress License No, r Z Phone TYPE OF WELL/PUMP: NEW WELL.© WELL REPLACEMENT F1 DESTRUCTION 0 Out of Service Well 0 11 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE Ip. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 11 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS nIndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Eq Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications [ IE'I Public CI Other n Delta Depth of Grout Seal Type of Grout I II Irrigation Approx. Depth I I Eastern Surface Seal Installed by r i Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ED Well Diameter Sealing Material & Depth I! Depth Filler Material epth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION K DESTRUCTION t I (No septic system permitted if public sewer is i available within 200 feet.M Installation will serve: Residence_ Commercial Other II Number of living units: Number of bedrooms ' Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. 0 Type/Mfg Capacity ® No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well rE� --- Foundation Property Line ______ l LEACHING LINE Cl No. & Length of lines _ _ 0 Total length/size FILTER BED ❑ Distance to nearest-, Well Foundation 's Property Line SEEPAGE PITS IJ Depth $i:e Number SUMPS r Ll Distance to nearest: Well If)Z3'— Foundation-` Q Property Line 1560SAL 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 f-d rulas 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 shalt employ persons subject to workman's compensa- tion laws of California." ,I The applicant must call for 11 r d inspections. Complete drawing on reverse side. i I Signed %.- �� — Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date '0 res I Pit or Grout Inspection by Date Final Inspection Date Additional Comments: Applicant _ Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services I 1601 E. Hazelton Ave.. F 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT NO. . EH 13-21 fREV.v K 51 i EH 11.25 'F