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APPLICATION FOR PERMIT s SAN JOAQUIN COUNTY PUBLIC,HEALTH SERVICES �*s I' ENVIRONMENTAL HEALTH, DIVISION 1601 T. EAZELTON AVE. , PHONE (209)468-3420 P O BOR 2009, STOCKTON, CA 95201 JUN ' 1991 IT EXPIRES 1 YEAR FROM DATE - NvIRofVMEfNTAL HEALTH (Complete in Triplicate) PERM IT/5ERV;CES ` Application is hereby madeto 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. �.i�`/y✓ I � __ City Lot Size .lab Address � s Ij Owner's Name Address Phone r Contractor dress s- No Phone I TYPE OF WELLIPUMP: 1� NEW WELL _R WELL REPLA EMENT_❑ DESTRUCTION ❑ put of Service Well L� SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 PUMP INSTALLATION D � DISTANCE TO NEAREST: SEPTIC TANK" SEWER LINES DISPOSAL FLD., PROP. LINE FOUNDATION = AGRICULTURE WELL = OTHER WELL PITS/SUMPS s INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Excavation Dia. of Well a n Industrial ❑ Open Bottom ' ❑ Manteca C sing t04 Domestic/Private 1-Gravel Pack Tracy Type of Casing` 441CA6 __ Specifications Il Public CZ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation ��Approx. Depth �I I East� acern SurfSeal Installed by l Repair Work Done L7 Typefof-pump I .P. State Work Dona Well Destruction ElWell Diameter Sealing Material Depth Depth --"" Filler Material& Depth TYPE OF SEPTIC WORK:, NEW INSTALLATI4N..l l REPAIR/ADDITION !.I DESTRUCTION I I (No septic system perrnitted if public sewer is V1 !I available within 200 feet.) :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 t SEPTIC TANK. O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Ij Method of Disposal. I ; C Distance to nearest: Well Foundation Property Line 4 E L LEACHING LINE ❑ No. & Length of lines Total length/size— FILTER ength/size FILTER BED Cl Distance to nearest: Well Foundation Property Line ' SEEPAGE PITS 11 Depth Size Number 9- _ -- � - SUMPS Ll Distance to nearest: Well Foundation Property Lina 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 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 hat in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Cal' nla.' The applic t cal a squire - spec'ons. C&Mplete drawing on re se side. �-- Signed X Title: r Date: 6 I DEPARTMENT USE ONLY is Date Application Accepted by - Pit or Grout Inspection by a F 7l Inspe ion y Additional Comments: 4 Applicant – Return all copies to: San Joaquin County Public Health OF Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 s' FEE AMOUNT DUE REMITTED CASH RECEIVED BY DATE PERM17'N0. INFO d Kw— � (j + EH 13-24 IREY.I/A51 N� { 1 " % JWA EH 14-Ie � - , !I