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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 eqD P O BOX 2009, STOCKTON, CA 95201 HERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete iia 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 Ordin rtes No. ;VJn411V d2 and the Rules and Regulations of San Joaquin County Public Health Services�;q aZP X Job Address Cityt Size/Acreage C CJ Owner's Name Address Phone ^� Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL O WELL REPLACE NT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM EPAIR ❑ OTHER Q Monitoring Well ca DISTANCE TO NEAREST: SEPTIC TANK SEWER NES DISPOSAL FLD. PROP. UNE FOUNDATION AGRICUL RE W LL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA C STRUCTION SPECIFICATIONS L7 Industrial ❑ Open Bottom ❑ Manteca a. of Well Excavation Dia. of Well Casing Ll Domestic/Private Cl Gravel Pack ❑ Tracy T e of Casing Specifications I') Public Cl Other (-1 Delta De th of Grout Seal Type of Grout I i Irrigation _ Approx. Depth I i Eastern Su ce Seal Installed by Repair Work Done L7- Type of Pump .P. State Work Done Well Destruction ❑ Well Diameter Sealing ►date al & Depth Depth Filler Materia & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer Is available within 200 feet,) Installaiirin will serve: Residence commercial_ Other Number of living units:L__ Number o"d. roomsi el Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg b apacity. No. Compartments PKG. TREATMENT PLT. ❑ / Method of Dispos I Distance to nearest: Well Foundation' ` Property Line LEACHING LINE Ll No. & Length of lines Total length/size IY_x d 67IFtr kgh FILTER BED 'Distance to nearest. Well Foundation� Property Line . SEEPAGE PITS I I Depth Size Number 4 SUMPS L! 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 or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shalt 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 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 Califor The applicant ust ca or all r uired ct_ion o-Plate drawing on r side, Signed ' Title: Date: F R PARTMENT USE ONLY ` I Application Accepted by Date 0— rea L _q Pit or Grout Inspection by Date Final Inspection b Dat �f P 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 FEE INFO A OUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT�NO. + E4i tt.�INEV.iinS! Ito Is