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f APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES s :)1n8s111ffl3d ENVIRONMENTAL HEALTH DIVISION y 'YIH 1V1N3WNM 1601 E. HAZELTON AVE. , PRONE (209)468-34Zb LANI P 0 BOX 2009, STOCKTON, CA 95201 O Nn,ri kMIT EXPIRES 1 YEAR FROM DATE (Complete in Triplicate) CZA1303H Application is hereby made,to San Joaquin County for a permit to construct and/or install the worlt�;&"hoed. This t application is made in compliance with San Joaquin County Ordinance No. 549 and 1562 and the Rules and Regulations of San Joaquin County Public Health Services. s Job Address J A C L*,AeCity f Lot Size/Acreage rr �l Owner's Name C�;� C-+C W�M Arddress F y- s G�YolKePhone Zd 531-6!;_40 6©x L [ala Contractor W� I f� Address OCA License License No.'3:7_J?_T_4JL5" Phonefo - TYPE OF WELL/PUMP: i�, NEW WELL ID WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ M REPAIR ED OTHER O Monitoring well DISTANCE TO NEAREST: SEPTIC TANK SEWER LI E5 00 l DISPOSAL FLD, JA- PROP. LINE ! 1MW _n FOUNDATION 45�------ AGRICULTURE WELL OTHER WELL � �� PITS/SUMPS -Alk INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFiCATIPNS it Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 177 Domestic/Private Gravel Pack ❑ Tracy � �/ Type of Casing PVC c7 Specifications -10-070 S'tof I'1 Public /ClPther fl pelta ipl Depth of Grout Seal .N { Type of Grout w 1 i Irrigation 74 Approx. Depth 11 Eastern Surface Seal Installed by 4 a+H I Repair Work Done ❑ Type of Pump iuAr H.P. Ai /4r State Work Done_/k/.4 Well Destruction ❑ Well Diameter Sealing Material & Depth I�rSy7/E Bps Depth C P& Filler Material 5 Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIRIADDITI0N I ! DESTRUCTION l I (No septic system permitted it public sewer is available within 200 feet) h Installation will serve: Residence_ Commercial— Other �l 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. ❑ i� Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/sire ` rV\ FILTER BED CI Distance to nearest: Well Foundation Property Line r SEEPAGE PITS 11 Depth Size _ Number ` SUMPS Ll Qistance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ii 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 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, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicanj must call for all required inspections. Complete dr,7vyingl. n„r�yorse side. SignedATn' ff Title: r.+r{ Oq Date: I `�nr�ftk ART E ONLY Application Accepted by Date Ar s Pit or Grout Inspection by Data r Final Inspection by Date 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 '`MOUNT DIE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. « EH 1324 IS EV.»KSi