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APPLICATION- FOR PERMIT ;f SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION y 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, 'CA 95201PERUTT i EXP RES 1 YEAR k'R M DATAaVED _ j (Complete in Triplicate) Application ie hereby made to San Joaquin County fora permit to construct and/or install the work herein described. This application is made in e .1th Services, with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Re Joaquin County Public Health Services. gulatione of San Job Address -� City Lot Size/Acreage Owner's Name .1 /iI�-✓� (� � � '� ddress /�% � Phone ' Contractor ddress License No. ��/ II " , TYPE OF WELUPUMP: ,. NEW WELL ❑ Phone WELL REPLACEME DESTRUCTION ❑ Out of Service We11 C1 PUMP INSTALLATION SYSTEM REPAI ❑ OTHER ❑ Monitoring Well i DISTANCE TO NEAREST: SEPTIC TANK `� SEWER LINES --r 0 r FOUNDATION I DISPOSAL FLD. PROP LINE: - AGRICULTURE WELL �-' OTHER WELL PI75/SUMP / INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ;r0-Manteca- --- .- h Dia:of Well Excavation ----- 'R' Domestic/Private Gravel Pack ❑ Trac 9 Dia. of Well Casing F 1'1 Public y Type of Casing__ 'i f.1 Other Specifications n Delta Depth of Giout Seal Type of Grout I I Irrigation �o Approx. Depth I I Eastern y S riace Seal lristalied If 3 Repair Work Dane LJType of Pum / � � �• p by Well Destruction H.P. State Work Done _ IM 0 Well Diameter ^ Se&ling": Material & Depth I Depth Filler Material & Depth Ij TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAfRlApD17lON I I DESTRUCTfON I I INo septic system permitted if public sewer is C /� Installation will serve: Residence Commercial available within 200 feet) _ Other Number of living units: �Number of bedrooms Character of soil to a depth of 3 feet: rr SEPTIC TANK. ❑ Type/Mfg r.� Water table depth PKG. TREATMENT PLT, ❑ Capacity No. Compartments IM -- 'A_ Method of Disposal Distance to nearest: Well Foundation Property Line I� LEACHING LINE ❑ No. & Length of lines'- Ij FILTER BED ❑ Distance to nearest: yyejl Total length/size :M ` Foundation Property Line 1 1 SEEPAGE PITS ll Depth Size _ Number SUMPS l:1 Distance to nearest: Welt I. DISPOSAL PONDS p Foundation Property Line I hereby certify that I have preparedthis application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an t 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 shalt not t employ an ' , g 1 P Y y person in such manner as to become subject to workman's compensati6n laws of California." Contractor's hiring or sub-contractin signature certifies the following: "i certify that in the performance of the work for which this ermit is issued, !shall employ tion laws of California." ., E' W p y persons subject to workman's compensa- I The applicant urst c li i alr �= r Llf t h quire ' r rCompleti3•drawing on revarsa-side. .Y Signed Date: —rc 9 F R DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by �� r Date 'Final L_ _ �f4 -in c f .Additional Comments: �'- Date Applicant - Return all copies'to: San Joaquin unty. blit Health '` G -'_- ~---�Services;l�vironmental'�HealtN'P�rmi't/Services 1601 t. Hazelton Ave., P 0 Sox 2009, Stockton, CA 95201 I! FEE AMOUNT D!lE. Z- A It INFO AMOUNT REMITTED ti` RECEIVED BY, DATE PERMf7'NO. + EM 13-24(REV.l i n 51 r f t O r CH 14.20 10103 `f o-o 3��--Ilff