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i APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 j P O BOR 2009, STOCKTON, CA 95201 2ERMIT EXPIRES 1 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 1862 and the Rules and Regulations of San Joaquin County Public Health Servic a. Job Address 1 e., City j Lot Size/Acreage Phone �YLri1�� a - I V /r0 l _ .�/J ��_ Owner's Name Contractor �"� ��✓/ Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION C1 Out of Service Well ❑ PUMP INSTALLATION C7 SYSTEM REPAIR 0 OTHER ❑ ;�E itor �1e11 ❑ '4 DI CE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO, PR FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECT NS LI Industrial ❑ Open m ❑ Manteca Dia. of Well ation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack Tracy of Casing Specifications FI P�iblic L.1 Other ' Cl Depth of Grout Seal Type of Grout I Irritation _.Approx l I Eastern Su cal Installed by ' Repair Work pone ❑ T Pump H.P. tate Work pane_ Well Destruction Wel! Diameter Sealing Material & Depth Depth Filler Material & Depth / TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTIONINo septic system permitted if public sewer is available within 200 feet.) C/ Installation wilt serve: Residence J Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: j Water table depth / SEPTIC TANK. ❑ Type/Mfg}. aty No. Compartments PKG. TREATMENT PLT. 0 od of Disposal Distance to nearest: Well A -dgtion ; P tpMr, t f171t LEACHING LINE Cl No. & Length of lines pro O FILTER BED ❑ Distance t6 nearest: Well byFbAda1i �ifrp�1 y J - .Y� 0a UUII SEEPAGE PITS 14 Depth Sire ` u SUMPS LI Distance to nearest: Well Foundation Property Lie n DISPOSAL PONDS ❑ I hereby cartify 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 parson in such manner as to'bacome subject to workman's compensatiori 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 ,I for all required inspeions. Cqm plat drawing on reverse side. igned ' e GC!/ r'C�1' _ Date: OR ART_MENT USE ONLY Application Accepted by L^'17 Date_ioV Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: f 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 AMOUNTS (REMITTED CK I CASH RECEIVED BY DATE PERMIT'NO. + EH 13.24(REV,I/x5) Ly � } � 10 EN 14.28 i