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k • APPLICATION FOR PERMIT r a . �� • SAN .IOAQUIN COUNTY U`B HEALTH SERVICES ENVIRONMENT HEALTH DIVISION 1601 E. HAZELTON AV * ' PHONE (209)468-3420 P O BOX 2009, ITOCKTON, CA 95201 RERMIT i EXPIRES 1 !EAR FRQM DATE ISSUED (Complete n Triplicate) i Application is hereby made.to San Joaquin County for a perms to construct and/or install the work herein described. This application is made in compliance with Sari Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San r Joaquin County Public Health Services. Job Address fl��'u�� City .5� Lot Size/Acreage t Owner's Name / +s�L l�/�LO f Address - Phone t ContractorLg�Mr:l _Address 1 License No, A5)e1VPhone/ ?2'Z.�D TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑tip w DESTRUCTION ❑ Out of Service Well 0 .�'-- PUMP INSTALLATION ❑ SY fTEM REPAIR 111 OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST." SEPTIC TANK DISPOSAL FLD: PROP-LINE FOUNDATION AGRICULTURE 1ki.t. OTHER WELL PITS/SUMPS _ I INTENDED USE TYPE OF WELL PROBLEM AREA CO STRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom D Manteca Dia.'lof Well Excavation Dia. of Well Casing C1 Domestic/Private ❑ Gravel Pack 0-Tracy- .- Typ pkkpof Casing - - ----------. Specifications 1'1 Public C1 Other 1-1 Delta Dep Tt of Grout Seal Type of Grout I I Irrigation �.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done ' Well Destruction ❑ Well Diameter Sealing Matrrial & Depth Depth 6 Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIRIADDITIO DESTRUCTION i I (No septic system permitted it public sewer is available within 200 feet.I Installation will serve: Residence Commercial A� Other �" s Number of loving units: Number of bedrooms - Character of soil to a depth of,3 feet: Water table depth SEPTIC TANK ❑ "Type/Mfg i Capacity No. Compartments PKG. TREATMENTYLT..❑.. rty � � Method of Disposal Distance to nearest: Well F nda6on Property Line LEACHING LINE pl No. & Length of lines.. 4 Total.length/size FILTER BED 0 Distance to nearest: Well 00 V"" F kundation _ /� Property Line SEEPAGE PITS i Or Depth Z�,r Size 33,1 Number SUMPS r Ll Distance to nearest: Well gva r F runaation T ,[�2' _ Property Line 4D DISPOSAL PONDS © ') - a I hereby certify that I have prepared this application and that the work will a 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 cam ensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for whit 'this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." E I 4 The applicant must call for all required inspections, Complete drawing on r!erse side. s . Signed e Title: . Date: , ' R DEPART ENT USE ONLY Application Accepted byDate _ Area r In Pit or Grout Inspection by Date ! Final Inspection by Data Additional Comments: ; Applicant - Return all copies to:c..SanJoaquin County PuSlic ealth Services, Environmental Heillth Permit/Services 1601 E. Hazelton Ave., P 0x 2009, Stockton, CA 95201 E INFO 'FEE AMOUNT DUE AMOUNT REMITTED CA H RECEIVED BY DATE ERMiT N0, + EH 13-24 IREV.1/x55 EH 14-A �� r1�� Ca� O � t 6