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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES � t k ENVIRONMENTAL HEALTH DIVISION W 1601 E. HAZELTON AVE. , PHONE (209)465-3420 P O BOIL 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE EDS\] (Complete in Triplicate) Application 1s 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 Services. XTA J0 il/M H Job Address City Lot Size/Acreage Owner's Name : Address 49 lfotge Phone �CZ- Z299 Contractor le AddressLicense No.V /-O- Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 1-7 DESTRUCTION ❑ Out of Service Well L1 l PUMP INSTALLATION ❑ SYSTEM REPAIR Ll OTHER © Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISP L FLO. PROP. LINE ` FOUNDATION AGRICULTURE WELL ER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRU SPECIFICATIONS C7 Industrial C1 Open Bottom ❑ MantecaA�ia. ell Excavation Dia. of Well Casing Ll Domestic/Private ❑ Gravel Pack ❑ Tracyasing Specifications p H Public fa Other n Delta Depth of Grout Seal- � Type of Grout �} I i Irrigation Approx.'bepth I i E rn Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth `� Filler Material & Depth t TYPE OF SEPTIC WORK: NEW INSTALLATION 11.;tREPAT/ADDITION I I DESTRUCTION (No septic system permitted it public sewer is available within 200 feet.) 14 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%` k 13 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ mmR Method of Disposal Distance to nearest: Well Foundation Property Line - . LEACHING LINE Cl No. & Length of lines } ' Total length/size ,r FILTER BED Cl Distance to nearest: Well Foundatiori- j Property Line SEEPAGE PITS 11 Depth ! Size __.•^—Number SUMPS- LI Distance to nearest: Well Foundation . Property Line DISPOSAL PONDS ❑ I hereby certify that t 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 at California." The applicant us t call for all rqW1tp0 inspe ons. Cdrriplete�draw ng.on reverse si Signed 6 Title: Date: MCD—EPAIRTMENT USE ONLY Application Accepted by ' Date '0 1 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 FEEINFO 3AMOUN�TpDUE AMOUNT REMITTED C K H RECEIVED BY DATE P/HERMITNO... + EH 4-20(REV.tiAS) S