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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 PERMIT EXPIRES 1 YEAR FROM-DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or iii"e tall 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. Job Address City Lot Size/Acreage Owner's Name Address s` a- Phone c Contractordress , License No. ; hone 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 FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS E Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications I'1 Public 11 Other ❑ Delta Depth of Grout Seal Type of Grout I Irrigation _Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diarrleter Sealing-Material & Depth a !v Depth Filler Material b Depth+. f TYPE OF SEPTIC WORK: NEW INSTALLATION [Or REPAIR/ADDITION 1 I DESTRUCTION I I (No'septic system permitted it public sewer is i available within 200 feet.) Installation will serve: Residence !_ Commercial—,_.. Other ` r C Number of living units: --I— Number of bedrooms Character of soil to a depth of 3 feet: Water table depth i SEPTIC TANK. ❑ Type/Mfg a. Capacity No. Compartments - i PKG. TREATMENT PLT. 0 Method of osal Distance to nearest: Well Foundation Property Line ' LEACHING LINE D No. & Length of lines Total length/size o i FILTER BED ❑ Distance to nearest: Well_ Foundation _ Property Line EEPAGE PI 11 Depth Size Number LIMPS U Distance to nearest: well Foundation - �(� Property Line s DISPOSAL PONDS ❑ 1 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 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 u I for II r r inspections. C late drawing on reverse side. Signed Title: SJt.,.r.,.a Date: 0' p FOR DEPARTMENT USE ONLY r1 pp kation Accepted by w :lk,. c.e.,.1,,r,. -t Date a 3^� Area . ? c� Pit/or Grout Inspection by�_!� Data`s �l �6) Final Inspection by � Dates Z C1~� --A ditional Comments: Applicant - Return all copies to, San Joaquin County Public Health Services; Environmental Health Permit/Services 16oi E. Hazelton Ave., P O Box 2409, Stockton, CA 95201 CK 0 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0. !S « EK 13-24(REV.1 nS) EH—26