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APPLICATION YOR PERMIT r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 �MI�ACHADO JaCktOf,Q C. P O BOX 2009, STOCSTON, CA 65201 oad Stockton, CAIIfOrnia 95215 ��✓ PERMITEXPIRES 1 YEAR FROM DATE ISSUED_ (Complete in Triplicate) . i 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 Services. i �Q Ccs CSC., -S E1 i Ct t Lot Size/Acreage Job Address 7_ 3 - Y � � Phone 1 Owner's Name Address { / I ContractorWLL Address �^- License No Phone/ ' I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT,❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR' OTHER Cl Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL 'PROBLEM AREA CONSTRUCTION SPECIFICATIONS i Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing VDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications j I'l Public 1-1 Other El Delta Depth'of Grout Seal Type of Grout 1 I I Irrigation —Approx. Depth 1 1 Eastern Surface Seal Installed by Repair Work Done � Type of Pump H,P. . State Work Done 4 Welt Destruction ❑ Well Diameter Sealing Material A Depth Depth Filler Material & Depth 0 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION i I DESTRUCTION I I-INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence T. Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE L1 No. & Length of lines Total ler%gth/size FILTER BED. ❑ Distance to nearest: Well f=oundation Property Line SEEPAGE PITS 11 Depth Size _ Number SUMPS Ll Distance to nearest: Welt Foundation Property Line j DISPOSAL PONDS ❑ 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 I 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, t 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 of California." The want t call for all requ' inspec ' ns. Ca lets drawing on reverse side. Signed Title: ! Date: . n AOR DEPARTMENT USE ONLY rI Application Accepted by f'1`h \�\T 9 NAAkCs6h&A Data D Area + Pit or Grout Inspection by Date Final Inspection by ° Date l 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 INFO AMOUNT DUE AMOUNT REMITTED CASHff FR�;D BY DATE PERMIT'NO. . EH13-24(REV,I/K5) ✓' —~IZ clo 'Ze - 3 EH¢4.26 1 1 - i