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t APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL.. HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 P O BOIL 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1-YEAR FRQM DATE ISaUED (Complete in Triplicate) 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 Servic s Job Address Cit of Size/Acreage Owner's Name Address .Z. e I/ll PJ - Phone 1 S v` /� /�� STa�.✓ �y 6 Contractor dress r0 ��hZ License Nof Z / Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Weil ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR L 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 Cl Ind stria! ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1/I estic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications I'1 Public (] Other i 1 Delta Depth of Grout Seal Type of Grout I I Irrigation /—.Approx. Depth I I E tern Su�jace Seal-Installed by - Repair Work Done 4- Type of Pump ..1 G ' H.P / State Work`Do_ne d rI Well Destruction. ❑'� Well Diameter Sealing Material & Depth s y Depth Filler Material & Depth 4 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I i INa-septic system permitted it public sewer is "�}V 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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation a Property line LEACHING LINE ❑ No. & Length of lines F<7� Total length/sire + FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire Number SUMPS LI Distance to nearest: Well Foundation Property Line 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 ,t licen 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 peso such man ar as to become subject to workman's compensation laws of California." Contractor's hiring of subcontracting signature certifies the fol ing: "I cartify at in the perform ce of th��d, for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of alifarnia." The applic nt mu call for quired ' s _&ids. Signed Title: Date: OR TMENT USE ONLY Application Accepted byl� Date i {1� Area Pit or Grout Inspection by Date Final Inspection by DateA� Additional Comments: 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 INFO FEE AMOUNT DtJfi AMOUNT REMITTED C SH RECEIVED BY BATE PERMIT'NO. + EH U-24(A EV, iK51 - D ['� 7/1 l� D g7,5 -� EH iM2a t � ( G i