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j - APPLICATION FOR PERMIT I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ;i ENVIRONMENTAL HEALTH DIVISION 1601 E, HAZELTON AVE. , PHONE 12091468-3420 S U L 2 3 � P O BOX 2009, STOCKTON, CA 95201 ENViROWENTAL HEALTH PERMIT EXPIRES 1 YEAR FROM DATE ISS_U__ED PFRM1"T/SEJRV1:CSS .� (Complete in Triplicate) i 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 cat�liance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. . / Job Address _� �� F C"PIdt-vt ( 4UIP- City 'TrOLL�4-_ Lot Size/Acreage Owner's Name 1LY KSQigr/ e- 10011C_ Address � onje- r� Contractor GIUMAddress I License No. YgItS9a Phone 6 7- TYPE OF WELL/PUMP: NEW WELEL.L] WELL REPLACEMENT ❑ DESTRUCTION Out of Service Well ❑ f T PUIMP INSTALLATION-0F SYSTEM REPAIR ❑ OTHER'(d Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS D Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Weil Casing [❑ Domestic/Private ❑�Dlher avel Pack C1 Tracy Type of Casing. Specifications f I'1 Public i.1 n Delta Depth of Grout Seal Type of Grout0I i Irrigation �Approx. Depth I 1 Eastern Surface Seal Installed by i, Repair Work Done L3 Type of Pump H.P. State Work Done W 1 1 Sealing Material & Depth in ,,,L" )l Destruction II DiameterItz {l SO f it h Filler Material & Depth _ 44 PH fn1J.LL2 ^^ TYPE OF SEPTIC WOOK: N W INSTALLATION I I REPAIRIADDITION i I DESTRUCTION l 1 (No septic system permitted if public sewer is F n I: w•>E�,. 3 — ;t5'�•T C-e-x) available within 200 feet.) { Installation will serve: Residence� Commercial— Other Number of living units: �M Number of bedrooms Character of soil to a depthp'of 3 feet: Water table depth SEPTIC TANK. © .Type/Mfg Capacity No. Compartments r PKG. TREATMENT PLT, ❑ Method of Disposal I�Oistance to nearest; Well Foundation Property Line LEACHING LINE D No. & Length of lines Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line r kSEEPAGE PITS I 1 CDepth Size Number SUMPS SLI IDistance to nearest: �. Well Foundation Pto e. Line DISPOSAL PONDS 1211. 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 manner as to become subject to workmen's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I cartifI 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." i i The applicantall fpip all )red inspections. Complete drawing on r rse side. y Signed X Title: Date: FO t DEPARTMENT USE ONLY Application Accepted by Date Area i Pit or Grout Inspection,by II� Date Final Inspection by ate 1 !IMAdditional Comments: Applicant – Return all coplea to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009. Stockton, CA 95201 IF 0 AMOUNT DUE ' AMOUNT REMITTEO CASH RECEIVED BY DATE PERMIT•N0. + EH 13-21)REV.tin 51tJ6J � a D En 962s A :i