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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 0 BOR 2009, STOCKTON, CA 95201 PEMIT ERP,IRES 1 YEAR FROM D TTs ISt2UE} in. Triplicate) (Complete P 1 licate) 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 Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address O /1L City Lot Size/Acreage Owner's^NamePhone Address Contractor L _ &It f. f Address License No. 7 Phone TYPE OF WELL/PUMP: NEW WELL Q WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP.-LINE ` FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS ` r' INTENDED USE r TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 171 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 11-Domestic/Private ❑ Gravel Pack , ❑ Tracy Type of Casing Specifications - 1'I Public El Other � n Delta Depth of Grout Seal -, Type of Grout I I Irrigallor Approx.'Depth I I Eastern Surface Seal installed by Repair Work'Done 0 Type of Pump:. ' t H.P. State Work pone Wall Destructiori'N. p Well Diameter Sealing Material & Depth t { ., f Depth Filler Material & Depth - TYPE OF SEPTIC WORK:,,1NEW INSTALLATION REPAIR/ADDITION ( l DESTRUCTION I I-INo septic system permitted if public sewer is d } 1. available within 200 feet.) Installation.will serve: Residence� .Commercial� Other # Number ot'living units: . dumber of bedrooms 4 sh Character K � Water table depth!- 'soil to a depth of 3 feet:' s (� r SEPTIC TANK. `. ype/Mig `V _ t r t*/ 4 ' •--_&A-C, d_e_ Capacity ft�., No. Compartments.. PKG. TREATMENT PLT. 0 `'; : Method of Disppsal Z Distance to nearest: Well. T��r� Foundation # - Abu-�-- Property Line _ LEACHING LINE No. & Length of lines.* - FILTER BED �- Tora! length/size ❑ Distance to nearest:. Well-�W� Fogndation. Property Eine SEEPAGE PITS l I Depth Size- - Nurftber SUMPSDistance to nearest: Well Foundation. DISPOSAL PONDS_ ❑ —�s�— - Property Linew� _ ` , 3 I hereby certify that I Saye prepared this application and that;the work will be done in accordance with San Joaquin county or rules and regulations ofthe San Joaquin.County dinances, state laws, and 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 t not 1 employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting sins 11 ` 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." -lee - The applicant must call for all r quired inspeotions: Complete drawing on reverse side. ` Signed mTitle: i Date: FO" DEPARTMENT USE.ONLY f Application cceptad by Date �� Area Pit or Grout Inspection by Date Final Insp c ion by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health t t Services, Environmental Health Permit/Services :1601 E. Hazelton Ave.,/P 0 Box 2009, Stockton, CA 95201 fi r FEE AMOUNT DUE AMOUNT REMITTED CASH INFO RECEIVED'Sy. DATE PERMIT'NO.-- • EH t3-24IAEY.t EH 14.26 �' r �� / •�i� ��^" •' �I I y - �