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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOR 2009, STOCKTON, CA 95201 , E%P RES 1 YEAR FR M DATE (Complete is Triplicate) Application is made compliance withusaanJooaquinfor County ordinanceconstruct No. 549 andand/or IB62install and thethe Rules andherein Regulationsdescribed. of San Thisapplication is made compliance Joaquin County Public Health Services. r � �� 8 City Lot Size/Acreage i Job Address v r �� f f �. /V r �rddr Phone /� Q d� Owner's Name )� S� a Zb /� k 6iq License No. Phone 3� 0 9 Contractor �d Address TYPE OF WELLIPUMP: W WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION�I out of Service Well ❑ OTHER ❑ �Monitoring Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ i SEWER LINES _.�---- DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS FOUNDATION AGRICULTURE WELL OTHER WELL—- - I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing n Industrial C3Open Bottom 0 Manteca Dia. of Well Excavation Specifications Type of Casing is Domestic/Private Cl Gravel Pack C1 Tracy Depth of Grout Seal Type of Grout I-1 Public (Z Other F)-Delta I I Irrigation _.Approx. Depth 4 I Eastern Surface Seal installed by H p " State Work Dane.._. li Repair Work Done 0 Type of Pump // Sealing Material & Depth ' Well Destruction Well Diameter Filler Material & Depth Depth ted system TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I i availablelw thin 200 feeti.) if public sewer is ce Ins;alfation wilt`se'rv"e:"Resident�—.Co .: mmercial T_Othe rr l Number of living units: Number of bedrooms Water table depth i Character of soil to a depth of 3 feet: No. Compartments SEPTIC TANK. ❑ Type/Mfg Capacity— PKG. TREATMENT PLT. C) Method of Disposal Distance to nearest: WeII Foundation Property Line F LEACHING LINE LlNo. & Length of lines Total length/size FILTER BED CI Distance�to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number i SUMPS LI Distance to nearest: WeII 1_� Foundation Property Line DISPOSAL PONDS ❑ f I 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 mannar 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 worts for which this permit is issued, I shall employ persons subject to workman's compensa- tion'laws of California." Ki11' applicant II or all squire .i cons. o plate drawing-0 asidened X_ Title: Date: j F DEPARTMENT USE ONLY l Date -- Area Application Accepted i y Final inspection by Date Pit or Grout Inspection by Date — f ts:Additional Commenf fA�QQ_ o� u^rE H.��o� e P6r d = 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 AMOVNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'N0. iNF 4 a EH17241REV.1/nal 3 5i EH 14.25 i