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{Tl APPLICATION FOR PERMIT e SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICPS � , � -� "� �� •I ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 !" P O BOX 2009, STOCKTON, CA :95201 T J �. REMIT EXPIRES i_ YEAR FROM DAIS' ISSUED, NTA�H�AL�H t (Complete in Triplicate) �NVI[t�NMS�RVIG�S �� PERM 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 Ordina a No. 549 and:1862 and the Rules and Regulations of San Joaquin County Public Health services. Job Address City ter- "� LotSize/Acreage rt { Owner's Name a'• _ Address / r r ?Is Phone Contractor r.44P'(0A j t �� Add etssss �M' � Lr+ � License No r-�a s� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 Monitoring Well L7 DISTANCE TO NEAREST: SEPTIC TANK �R SEWER LINES 300 DISPOSAL FLD. PROP. LINE FOUNOATION _ r11f- - `AGRICULTURE WELL OTHER WELL PITS/SUMP" INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing f Domestic/Private Cl Gravel Pack , ❑ Tracy., Type of Casing Specifications I'I Public fa Other n Delta Depth of Grout Seal Type of Grout i I Irrigation -Approx, Depth I I Eastern Surface Seal Installed by I Repair Work Done 0 . Type of Pump H.P. State Work Done Well Destruction O. Well Diameter Sealing Material 6 Depth Depth Filler Material 8 Depth {. TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION i I -DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feat.) 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 PKG, TREATMENT PLT. ❑ t Method of Disposal ' Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest. Well Foundation Property Line i SEEPAGE PITS I I Depth Size Number SUMPS _ J C! Distance-,toLnearest•.,..._Well' rFaundation- 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 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 ceJaliqatired in the performance of thework for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Californla.The appl-t{cant must call,for inspections. Complete drawing on reverse side. Signed X �✓ 1 Title: JC7`�r ��(o r Date:. r 46Y FOR DEPARTMENT USE ONLY ] g Application Accepted by ` Date 1 Area L Pit or Grout Inspection by Date l� Final Inspection by Date r Additional Comments: 62 r. Applicant - Return 911 copies to: San Joaquin County Public Health ca Services, Environmental Health Permit/Services t 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT•NO. I; EH 13-2�c0.EV.trnsl I-N3 EH r�-26