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i ` APPLICATION FOR PERMIT i I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3 P 0 BOX 2009, STOCKTON, CA 95201 � `� PENIT RES 1 YEAR FROM DATE ISS2ED k (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install td. This application is made in co'liance with San Joaquin County Ordinance No. 549 and 1862 and the Ru gulations of San Joaquin County Public health Services. ,gyp ' 41 -eg Job Address Ili ^"' City ~ Lot Size/AcreagekZ! Owner's Name1e-e l-es„-`R-, f ) Phone Ih , 90 ao)C 7 QA Contractor Address E-rneol qKb`� License No. 3_�b3�� Phone —q TYPE OF WELL/P MP: i NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATI.O(V ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well DISTANCE TO NEAREST: SEPTIC TANK �! --- SEWER LINES /'324:D' DISPOSAL FLD,_L"S� PROP. LINE ( MU FOUNDATION AGRICULTURE WELL h�_ OTHER WELL��'Y,r&'1-" PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Zig ! ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation `, Dia. of Well Casing I, D Domestic/Private Gravel Pack ❑ Tracy r, Type of Casing PVC ScA- '70 Specifications d � I"i Public 0 Other fl Delta t Depth of Grout Seal +"o 4-t,L��0 ype of Grout I I lrrigation fL Approx. Depth I I Eastern $urfabe Seal Installed by (t Repair Work Done 0 Type of Pump N It H.P. State Work Done for i �` Sealing Material & Depth Welt Destruction O Well Diameter'�- Depth :4: Filler Material & Depth r TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I I INo septic system permitted if public sewer is I� available within 200 feat.I 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.❑ .11. Method of Disposal l Distance to nearest: Well Foundation Property Line r r .IM 1N/1f k LEACHING LINE D No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line II � SEEPAGE PITS 11 Depth Size � Number i � SUMPS Ll Distance to nearest: Well Foundation Property Line , DISPOSAL PONDS ❑ t� I hereby certify that I have prepared this application and that the work wilt 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 n employ any person in such manner as to become subject to workman's compensation laws of California," Contractor's hiring or sub-contracting signature '0 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." I The applic t must tali for all required i speelions. Co^mlete dw, pn reverse side. / - _ Date: Signed X 11 'O Tide: kf^o�ec+ qedpsir s 4-- FOR FOR DENLY y AreApplication Accepted b Pit or Grout Inspection by Date,? 3 al Inspection by Dats �U Fin Additional Comments: l� 0 Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 B. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE F INFO AMOUfNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE /PERMIT'NO. i : Eli t32�IREv.,iKsr I 35 �� ( 1777 v G��EH 4426 `I y