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APPLICATION FOR PERMIT IIS SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES , - I ENVIRONMENTAL HEALTH DIVISIONS 1601 E. HAZELTON AVE. , PHONE (209)468-3420 -B 2 S ' P O BOR 2009, STOCgTON, CA 95201 ENVIRONMEN-PAL HEALTH pERMTT EXP RES 1 YEAR FROM DATL JV_ED PERM f f/SE'RVICES ! (Complete is 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 Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public HealtServices. d 7 Job Address City Lot Size/Acreage J + ��1?�S �?►1� — Phone Owner's Name i Address Contras ar L Address License No,f, Phone' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well C1 -PUMP INSTALLATION ❑� 1 � ,+. S,YSTEM-REPAIR OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE } —FOUNDATION----------Y----AGRIGU�TLJRE-WEL-L- ---OTHER-W-EL-L-, PITS/SUMPS�—_ - INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS' Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing t.l Domestic/Private Cl Gravel Pack D Tracy Type of Casing i Specifications I'I PUblic ❑ Other F1 Delta Depth of Grout Seal Type of Grout r_ I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by ' •3� Repair Work Done 17 Type of Pump _ lg H .P. .5 _ State Work Done Wel! Destruction CI Well Diameter Well Material & Depth l Depth Filler Material & Depth a TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) 'I Installation will serve: Residence_ Commercial_ Other Number of living units: ' Number of bedrooms t lr� Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg . - - --- Capacity ' No. Compartments I� 1 PKG. TREATMENT PLT. C] ). r ..�,p ,__�.., 3 Method of Disposal Distance to nearest: Well R Foundation } Property Line—' F LEACHING LINE D No. & Length of lines 5• Total length/size 1 FILTER BED E) Distance to nearest: Welly Foundation _ Property Line Q ` �:v",�y�.:�. SEEPAGE PITS. l_I. yDepth..- Size- Number _ R � SUMPS LI Distance to nares[ Well '° 'foundations yProperty Line 1 DISPOSAL PONDS ❑ 1 I hereby cenity that I have prepared this application and that the work,will ba'done in accordance with Sari 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°certifyAhat in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman'srcompensalion-laws of California." Contractor's-hiring or sub•conttacting signature certifies the toll i g: "I certify that in the performance of-the_work-for-which this permit-is issued-l•shall employ persdn`s subject to workman's compensa- tion laws of Cal or ia." The appli nt call for all req it d inspect! s. Complete drawing on ver a ids, t I Signed X Title: A A^ Date: �a�_1+ r R D ARTMENT USE ONLY o by Date Area Application Accepted Pit or Grout Inspection by Date Final Inspection by f Date 3 f Additional Comments: . e I Applicant - Return all copies to: San Joaquin County Public Health Services, Enviionmental lifealthPermit/Services 1601 E. Ratelton Ave ,.+ P Q Box 2009. Stockton, CA 95201 ti.r� Av L:4 FEE AMOUNT DUE. AMOUNT REMITTED CASH RECEIVED BY DATE E PERMITNo. INFO a EH 13.24 IFIEV.1/x51 - � .a ~ n EH 74.26