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i APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 -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 with San Joaquin County. Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health.Services. a C,/ Job Address -rQ �� City r�►T C- + Lot Size/Acreage +S- Owner's Name �^ Address -�� S. NCr 1 Phone Contractor ��'�� __Address License 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 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 61 Domestic/Private 0 Gravel Pack Cl Tracy Type of Casing Specifications Cl Public C1 Other U-1 Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I I Eastern Surface Soul installed by =fin Repair Work Done U Type of Pump H.P. State Work Done 5 Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material ti Depth TYPE Of SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial..4... Other1C_ Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth J4 SEPTIC TANK 9;,-Type/Mf: L rGA C� '`- Capacity ZD O No. Compartments Z-. PKG. TREATMENT PLT. ❑ I Method`ofrDiWsal e-C44-e_h L e+ Q Distance to nearest: Well Foundation & Property Line LEACHING LINE E�—No. & Length of lines �3 "2'�, rTotal length/size f ER BED , li�Di�sance to ne t: yvell 1 0 Founda;Ian �ts Propeny line o X / O 6 6 X- 1 0 Z /_0�K SEEPAGE PITS l I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line 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 rules and regulations of the San Joaquin County Home owner or licensed agent's signature cenifies 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 California." The applicant ust call for all requir 'nspec ' s. Co ete drawing on r vefse Ido Signed X_ Titfe: Date: FOR DEPARTMENT USE O LY Application Accepted by Date TA0 Area I` Pit or Grout Inspection by Date Final Inspection by Date l lqg4 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 FEE AMOUNT DUE AMOUNT REMITTED CK 9 RECEIVED BY DATE PERM17'N0. . EH t3-24(REV.1 5) - l/5�-�v x.17 9, 6 EH;4-26