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APPL I CA7--_%FOR PERM I T SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 P O BOR 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) k Application is hereby made.to San Joaquin County for a permit to construct and/or install the work herein described. This f 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. F Job AddressA. ' City r, Lot Size/Acreage Owner's Name.:::::— e Address /O Phone Contracto Addres c C-I" License No. d Phony TYPE OF WELL/PUMP: I NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service Well Gl PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing R'DomesticlPrivate Cl Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public El Other FI Delta Depth of Grout Seal -Type of Grout-- i I Irrigation ".Approx. Depth1 Eastern Surface Seal Installed by Repair Work Done �v Type of Pump H,P. State Work Do Well Destruction ❑ Well Diameter Sealing Material & Depth i Depth Filler Material &,Depth M TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAM-1ADDITION I I .]DESTRUCTION i I lNo septic system permitted if public sewer is ` J r ... . _ _ --available available within 200.f est.i Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms J/ Character of soil to a depth of 3 feet: Water table depth `r!/ 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 ' V Total length/size FILTER BED [1 Distance to nearest. Well t + Foundation Property Line M SEEPAGE PITS ( I Depth.. Size _ Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 r Home owner or licensed agent's signature certifies the following: "I certify that inti 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 cenify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman' comp sa- tion laws of California." "' The applicant it for all required inspect ' ns. Complete drawing on revs de. �� - Signed Title: Date: FOR EPARTMENT USE ONLY Application Accepted by L Date Area Pit or Grout Inspection by Date Final Inspection by Date^z ~� 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 AMOUNT DUE AMOUNT REMITTED CK RECEIVED 8Y L INFO CASH DATE PERMIT'N0. + EH 1321[REV.+/K 5) 0v (' -P9 �� EH 11.28 J