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.j APPLICATION FOR PERMIT ii SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ��y ENVIRONMENTAL HEALTH DIVISION 1601 R. RAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 EMIRES I YEAR Jd M (Complete in Triplicate) Application is hereby made,to San Joaquin county for a permit to construct and/or inate.1 the work herein described. This application1is made in compliance with San Joaquin County Ordinance Ito, 549 and 1$62 and the Rules and Regulations of San Joaquin County Public Healtrh�Services. Job Address dt f:g� City Lot Size/Acreage. II � Owner's Name "- Address _- Phone I Contractor Address OF License No. '? dY'�Phon ��` TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT El DESTRUCTION 0 Out of Service well 0 li PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well CJ DISTANCE Tp NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE Ij FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial !! 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications Il Public 1.-1 Other n Delta Depth of Grout Seal ___ Type of Grout I I lrrioalion ._._..Approx. Depth I I Eastern Surface Seal Installed by ' Repair Work Done- L3 Type of Pump H.P. State Work Done Well Destruction 0 Well Diameter Sealing Material & Depth I� Depth Filler Material & Depth TYPE OF SERTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITIO DESTRUCTION I 1 INo septic system permitted it public sewar is available within 200 feet.) -� installation will serve: Residence Commercial— Other Number of living i units: Number of bed ro s 3 _ Character at soil to a depth of 3 feet: = iA-.+�- _ Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments �- PKG. TREATMENT PLT.❑ Method of Disposal I' Distance to nearest; Well Fd'undation Property Line i LEACHING LINE C1 No. & Length of lines Total length/size F FILTER BED 0 Distance to nearest: Well AM Found ion 4— Property Line _ r i SEEP77- AGE PITS 1 1 Depth Size �,.Number \ „- SUMPS Ll Distance to nearest: Well, l� Foundation _ Property Line DISPOSAL PONDS 0 ie I hereby certify that i have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state.faws, and rules and regulations of the San Joaquin County I Home owner pr licensed agent's signature cenifies the following: "I certify that in the performance of the work for which this permit is issued, t shall not employ any pejson In such manner as to become subject to workman's compensation laws of California.”Contractors 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 applicant mu call to an requir fns tions. C plete drawing on reverse side. ZESigned ills: Date: FOR DEPARTMENT USE ONLY 1 7 Application Accepted by Date -3--q f Area �-G � r Pit Grout lntpactiort by Dales l Final Inspection by_ __ _ Dat Additional Comments: Applicant JIBeturn all copies to: San Joaquin County Public Health ! Services. ftvironmental Health Permit/Services 1641 E. Hazelton Ave., P 0 Sox 2009, Stockton. CA 95201 CK !INFFE AMOOuNT DUE AMOUNT REMITTEO CASH REGEtVEO BY DATE PEAMIY NO. + EH 13.24 1REV.11,6) K Wr `O V �' 00 23;I �.. EH 11.26