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APPLICATION FOR PERMIT�t SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 ,PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in 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 San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. rr c2q,34S , 01 �1�J 11 . }� mf7� Job Address �. ,Q/L-i? -gyp (� f f City/] jL�otSize/Acreage Owner's NameU , Address kqJ gL lr /CxY, Phone 1 r r .C$2-L� Phone $- a Contracto -C'" Address d 0 License No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 n Industrial ❑ Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing El Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'i Public C) Other rl Delta Depth of Grout Seal Type of Grout I I Irrivation ,_,_..Approx, Depth I i Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth F )ler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR! DDITION DESTRUCTION 1 I (No septic system permitted if public sewer is available within 200 feet.) , Installation will serve: Residence_eCommercial Other I Number of living units: Number of b oms �] Character of soil to a depth of 3 feet: Water table depth u t SEPTIC TANK T e/Mf a yA l; Capacity U0a No. Compartments 49 PKG. TREATMENT PLT. 111 / Method of DispPsal Distance to nearest: Well -50 Foundation 4� Property Line __57 t LEACHING LINE No. & Length of lines "` Total length/sire FILTER BED n Distance to nearest: Well ,5O, Foundation 4 C , _ Property Line I ' 1r SEEPAGE PITS Depth Sire_ 11(Q (Number SUMPS L! Distance to nearest: Well Ql Foundation„_-iI) Property Line 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, an rules and regulations-of The San Jbaquiri 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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant m t call for squired inspections. Complete drawing on reverse sed Signed X Title: -- -- � _. Date: 3sr F FOR DEPARTMENT USE ONLY 2 o Application Accepted by �i Date ! Z d Area or Grout inspection by� Date I Final Inspection by at (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 95201FEE ` INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT•NO. . EH 13-211REV.I/R!0 EH1,41-25