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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 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 install the work herein described. This application is made in co4liance with San Joaquin County Ordinance Ho. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 1 L f I r lull`1` 0 P-e_ 1 CC City k, Lot Size/Acreagec� Owner's Name r` Address Phone �Conlraclor [l Address 1�r � License NoC7'- Phone _ 7 TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Xe,,, Mopnitgri Well C1 V 1F S t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE W 6 tih FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C) Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing {l Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications - - — I'1 Public [a Other n Delta Depth of Grout Seal Type of Grout + l Irrigation -__._Approx. Depth I I Eastern Surface Seel Installed by Repair Work Done 0 Type of Pump H.P. State Work Done _ Well Destruction Cl Well--Diameter _ Sealing Material-8 Depth Depth Filler Material b Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION l I (No septic system permitted if public sewer is r 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. ❑ fi Method of Disposal 'l Distance to nearest: Well foundation Property Line N1 LEACHING LINE 0 No. & Length}of lines ' Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number I" SUMPS Ll Distance to nearest: Well Foundation Property Line f 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 is issued, I shall not employ any person in such mariner 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." 1 The applicant 79si call for all re ired inspections. Complete drawing on reverse side. I 4 Signe Title: Date: [ DEPARTMENT USE ONLY Application Accepted by �.ZR Date 3 -3 0 Area 13 5 Pit or Grout'Inspection by Date Final Inspection by Date Additional Commeiitsi Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., F 0 Sox 2009. Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH g + Err 13-II(REV.1/n5Y Eli c1-2a f �