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APPLIVATrrO-N 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 EXPIRES 1 YEAR FROM DATE ISSUED # (Complete in Triplicate) Application is hereby made,to San Joaquin County for a permit to construct end/or install the work herein described. This application is made in coupliance with San Joaquin County Ordinance.No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health � Services. - Job Address `4�STLe. City Md'80 f?LJ4 Lot Size/Acreage Owner's Name L UTLek Address �� s Phone Contractor_ Iz r CIA��'I•I`t -Address ./S4 �°'`� Ac`s License No. V43�/a _Phone TYPE OF WELL/PUMP: NEW WELL Cl WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ f OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELLY PITS/SUMPS INTENDED USE TYPE OF-WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial r ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing * Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications VI Public El Other n Delta Depth of Grout Seal Type of Grout i I Irritation _.Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump t H.P. State Work Done Well Destruction ❑ Well Diameter ! Sealing Material & Depth € Filler Material & Depth ' KJ Depth KJ TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l DESTRUCTION I 1 lNo septic system permitted if public sewer is available within 200 feet.1 Installation will serve: Residence Commercial Other Number of living units: Number of bedroomV__3 _ t r .0 I Character of soil to a depth of 3 feet: Water table depth y SEPTIC TANK Or-Type/Mfg Va Capacity No. Compartments Z �t PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well FoundationProperty Line LEACHING LINE 0 No. & Length of lines Notal length/size ; FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS 11 Depth I Size Number SUMPS LI Distance.to nearest: Well Foundation 'Property Line sr r 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 4 Home owner or licensed agent's signature certifies the following: "I certify that in theperformance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contriciof's hiring or sub-contracting signature certifies the following: "I certify that in the rformance of the work for which this permit is issuea, I shall employ persons subject to workman's compensa- tion laws of California." a ^" The applicant-must call for all re Or din ctions. Complete drawing on reverse side. .. t Signed X Title: Date: r ` OR DEPARTNtENT USE ONLY 06 Application Accepted by t�&Ms .�_ , s, n;. ` 1 Date. � rea Pit or Grout Inspection by�\ Date Final Inspection by Date Additional Comments: Applicant -'Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services t 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 4FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVE T' INFO CASH D BY DATE PERMI N0. j A qI - . EH 3.24(REV OC EN4-2ISC65 ["