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APPLICATION FOR PERMIT ° 1 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTOWAVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 ` . I PERMIT EXPIRES 1-YEAR FROM DAT ED (Complete in Triplicate) Application is hereby made.to San Joaquin County for a permit to construct and/or insta].1 the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Publics Health Services.�j�I/]I Job Address City T .. Lot Size/Acreage Owner's Name '�L � ._ Address Phone Contractor J GSS /&hl?!L Address License No. Phone v! yLOY ' f 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 c5� FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE T PE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C] Industrial Vopen Bottom ❑ Manteca Dia. of Well Excavati n y Dia. of Well Casing t.�omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 5 Specifications ,,� . ,.LJA y I'] Public El Other Cl �Delta Depth of Grout Seal . Type of Groutf:q�^LiL I I Irrigation —.Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done U Type of Pump Sal- H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION I I INo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence— Commercial.r... Other , Number of living units: Number of bedrooms r Character of soil to a depth of 3 feet: _ Water table depth f SEPTIC-TANK- —O—Type'lMfg Capacity —_� Nb-Compartments ' '"` 0. PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well ` Foundation Property Line r LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size. Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl 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 t 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 appliontt must scall for a"equired inspe tions. Complete drawing on reverse side. Signed X 'r g'� Title: Date: P ,5, f is a DEPARTMENT USE ONLY Application Accepted by Bateo 1+ Area 2 Pit or Grout Inspection byi Date 41/'D—Final Inspection by Date .2 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 i r INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE pPERMIT�NO. j + EH 19"20IRE{r,i/M51 Lv� A� 11312 -7_�.�.-1?- T L•Eli Z4-?a ✓ ` r