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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES k ENVIRONMENTAL HEALTH DIVISION 1601 E.„:HAZELTON AVE. , PHONE (209)468-3420 � _,P 0 BOR 2009, STOCKTON, CA 95201 PEMIT EXPIRES 1 YEAR FROM DATE SSUED (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 RegulationB of San Joaquin County Public Health Services..�r y- Job Address 3� G� ��rn S +'`7G� - City ;OG Tt Lot Size/Acreage �Q�e III Owner's Name �-.K A! � !cam+ Sa Address &A m e Phone 93 t` 14L1 ti k �t : !14 t Gi sS Address r' 1 � License No. 3�S Phone3�Y Contractor TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DTC DESTRUCTION Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR :❑� �` „ ,"' OTHER ❑ Monitoring Hell [3 DISTANCE TO NEAREST: SEPTIC TANK /D�} . - SEWER_LINES - -^-- - —wDISPOSAL FL�.IS� _PROP.,LINE i FOUNDATION AGRICULTURE WELL OTHER WELL 0a PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial + ❑ Open Bottom ❑ Manteca Dia. of Well Excavation L1 Dia. of Well Casing -C .�Oornestic/Private ;YGravel Pack ❑ Tracy Type of Casing Specifications F P� !'1 Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout c-e- I I Irrigation Z6t7 .Approx. Depth I 1 Eastern <Suriace Seal Installed by7 2'A r'` Repair Work Done 0 Type of Pump _ SSA H.P, State Work Done —��— Well Destructions R ❑ Well Diameter Sealing Material S Depth, r Depth Filler Material b Depth TYPE OF SEPTIC_WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I T INo septic system peimitted if public sewer is I -available within'20Mfeet,i Installation will serve: Residence— Commercial— Other Number ofliving units: Number of bedrooms i Character of soil to a depth of 3 feet: Water table,depth f SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ ay Method of Disposal Distance to nearest: Well �' Foundation Property Line - # 3 LEACHING LINE% ❑ No. & Length of lines• F Total length/size FILTER BED Ct Distance to nearest: Well �f Foundation Property Line ' I � SEEPAGE PITS ;-1 l-Depth Number F, SUMPS L1' ,Distanc6to nearest: Well, Foundation Property Line DISPOSAL PONDS ❑` s s� I hereby certify that I-have pPepared:this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and/n rules and regulations”of the San Joaquin County / J) 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 4 employ any person in such rnanner.as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature ll certifies the following: "I certify that in the perforrPance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California."' Theapplicant must,calL•for,all raqu red inspections. Complete drawing on reverse side. ( / Signed,X1it �` ` - -- Title: ._ Date: g-f !9� FO EPARTMENT USE ONLY Applicatia Accepted by Date �� - Area I 6� - �Z� Pit or Grout pection by Date �� -- Final Inspection by Da A& qZAdditional Comments: Applicant _ Return all copies to: San Joaquin County Public Health tri " i Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 1� VK AMOUNT DUE AMOUNT REMITTED CK RE ED BY DATE PEfiMI + EH A-21 IttEy.s i n 51 r��f1 / ! f EH i�-2a L 6L j �