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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES � S ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 N o w"' r � P O BOX 2009, STOCKTON,. CA 95201 PER V T X EXPIRES 1 YEAR FROM DATE l aa= 4.dThis (Complete in Triplicate) . Application its hereby made ,to San Joaquin County for a permit to construct and/or install the work herein des application is trade in compliance with San Joaquin County ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. f� City Lot Size/Acreage y\Job Address a Q f �/ 1"s 1 P �.. Address Phone n Owner's Name � - ` \ Address License No. . Phone i Contractor TYPE OF WELL/PU P; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ Monitoring Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ IDISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications Cl Domestic I Private C) Gravel Pack ❑ Tracy Type of Casing Type of Grout I'i Public I 1 Other n Delta T Depth of Grout Seal I I trsigation _.Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done + Sealing Material& Depth Wall Destruction (3 Well Diameter s Filler Material & Depth Depth TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION I�septic system permitted if public sewer is within 200 feet.) Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK. C) Type/Mfg Capacity � No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line W i LEACHING LINE Ll No. & Length of tines Total length/size FILTER BED n Distance to nearest: well Foundation Property Line SEEPAGE PITS 11 Depth Size Number s SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ F I hereby comity 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 I Home owner or licensed agent's signature cemifies 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 comity 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 st calf for all requir d inspections. Complete drawing on reverse side. 0 �S�ned X,_ �(J��AV Title: _�� 2 h _ Date: r R DEPARTMENT USE ONLY Application Accepted by Dat Area r� YV� Pit or Grout Inspection by Date Final Inspection by Date y 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 fEEHUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. IN G� ♦ EH 13.24 IREV.t/x 51 t? D �-✓ ' �r L O O -39 EH WX