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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 O BOR 2009, STOCKTON, CA 95201 PERIi[IT 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 vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address �`� �. City hot Size/Acreage Owner's Name Address, �� Phone Ai 0 i I ~� �B9aC� �8-5116s' Contract tlddtessGQ,��+D 1 License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well LJ DISTANCE FO-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 n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation .r .Dia. of Well Casing i, Fl Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing 'Specifications I"1 PUblic D Other n Delta Depth of Grout Seal Type of Grout r F I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by = Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth -./ Depth Filler Material 6 Depth s ~ TYPE OF SEPTIC WORK: NEW INSTALLATIOyqc<REPAIRIADDITION I i DESTRUCTION i I lNo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ _ rOther ! i Number of living units: Number of dtooms Character of soil to a depth of 3 feed —Water, table depth SEPTIC TANK - Type --",K r r Capacity *No. Compartments PKG.,TREATMENT PLT. ❑ 0 P Method of Disposal Distance to nearest: Well FFoundation Property Line' LEACHING LINE No. & Length of lines QTotal length/size FILTER BED ` C1 Distance to nearest: Well_ Foundation �C Property Line r SEEPAGE PITS 11 Depth Size - Number SUMPS f la 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 taws, an 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 work man'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." f The applicant m t call for u' d inspections. Complete`©awirig;on revers;e�pi r Signed X Title: Yi .'f Date: WAA �- FOR DEPARTMENT USE ONLY i Application Accepted by Date — Area - Pit or Grout Inspection by Date Final In'spectian by� Date o Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services i 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY (� DATE PERMIT N0. . EHt3 24(REV,r i h si � �j G 19"EH e426 / - 5