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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 95201 PFtiRi1fTT MIRES 1 YEAR FRAM DATE UED (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 Co ty Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Sery s. wr '/ -ZT IKCity Lot Size/Acreage ,-�� Job Address ^p T-2Af r/-� _ '�lJahone •�� Owner's Name �ddress Contractor -Q Address License No. Phoria r TYPE OF WELL/PUMP:, NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION ❑ Out of Service Well ❑ Monitoring Well ❑ 'LJ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE �J FOUNDATION N AGRICUL TURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f_1 Industrial ❑ Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing [l Domestic/Private ❑ Gravel Pack 0 Tracy r Type of Casing Specifications I'1 Public fa Other 1-1DeltaDepth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done LJ Type of Pump H.P, State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I ESTRUCTION 111No septic system permitted it public sewer is I available within 200 feet.I Installation will serve:' Residence✓* Commercial—rf Other ^ Number of living units: �_ Number of bedrooms% `^ f Character of soil to a depth of 3 Iasi: Water table depth 1 SEPTIC TANK p/Type/Mfg L Ciri7 C Capacity 12La�-- No. Compartments, 1 PKG. TREATMENT PLT. 0 r r Method of Disposal to n� �+-► Property Od Distance to nearest: Well _,�._!_ Foundation 0-�� p Y Line - 0 LEACHING LINE LW No. & Length of lines Z4 � 6O 9ta Ie /size ,.� FILTER BED ❑ •Distance to nearest. Wel! Foundation If p Property Line 10 - SEEPAGE PITS I I Depth Sire Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 note 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 must c I for I r i' nspec ions. C mpiete drawing on reverse side. ` Signed '� Title: Date: I { FOR USE ONLY z�l_-:�1113,* Aufaf Application Accepted by Date Pit or Grout Inspection by Date Final Inspection Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health k Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 ,FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO /10 a EH 13-241AEV.I/xbl EH'1446