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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES c� ' � r ail ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 SEP ' 8 1932 P O BOX 2009, STOCKTON, CA 95201 E:NViRONMENTAL HEALTH PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES (Complete in Triplicate) r Application Is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application In made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County /Public Health Service/s7. Job Address City a,rAmg�/- ot Size/Acreage Owner's Name • pBkXyAddress rdt r/ v Phone /YT . � 4-1 �� Contractor Address / 'T !�I a No.� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS Ir INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing \ Nd Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Public 11 Other fl Delta Depth of Grout Seal Type of Grout r I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by r� Repair Work Done Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter �f Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1 I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) 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 ❑ Type/Mfg Capacity No. Compartments r PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Wetl Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size r FILTER BED D Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number r SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 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 subcontracting 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 C nia." s The applica I c on requir ins ctio s. mplete drawing o r sides Signed �' . 74 Title:- Date: / F�iIEPA&*IIENT USE ONLY Application Accepted by EG l- � ^�'� -� Data -'7 Z- res Pit or Grout Inspection by Date Final Inspection by..5 Dater`% � u 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 INFO AMOUNT DUE AMOUNT REMITTED �H RECEIVED BY DATE PERMIT'N0. s. EH 14-201a EV.i/xsi EH 1420