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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$--3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ED . (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 1862 and the Rules and Regulations of San Joaquin County Public Health Services. .lab Address rx�1• �- 1 _ City Lot Si ze/Acreage Owner's Name (Li1'..Q�,b.( -� Address y� � a �• �� :_ _ _ _ Phone r i Contractoer _ Address License No.321Z7G Phone-_M-g i 0rS TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR L1 OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS f r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS * Industrial ❑ Open Bottom ❑ Manteca Dia: of Well Excavation Dia, of Well Casing t . _ J * Domestic/Private Gl Gravel Pack ❑ Tracy Type of Casing Specifications I'I Public 1-7 Other n Delta _._...-.. v. _1.�thof Grout Seal , Type of Grou - —.. '��" t • I I Irritation —.Approx. Depth I I Eastern Sace Seal Installed by `Repair Work Done 0 Type of Pump H.P. J, State Work Done 'e4.Well Destruction ❑ Well Diameter Sealing Material &-Depth " Depth _Filler Material & Depth `,TYPE AF.SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITIp DESTRUCTION I 1 INo septic system permitted if public sewer is �1 ' t _ available within 200 feet.l � r Installation will serve: Residence'� Commercial 'Other -yr � Z� Number of.-living..units: Number o edrotirns y6 Character of'stiil to a depth of 3 feet; Water table depth I SEPTIC TANK � ,� '�` Type/Mfg r r. Capacity-1-(0 - No. Compartments 19, PKG. TREATMENT PLT. ❑ t' I Method of Disposal Distance to nearest: Well ,Foundation�_ Property Line S., — j LEACHING LINE, ❑ No:& L gth of lines Total length/size FILTEf,I BEb+ ❑ "Distance to nearest: r Well Foundation Property Line SEEPAGE.PITS L I i Depth Sizes _ Number SUMPS LI Distance to nearest: Wel I� Foundation Property Line DISPOSAL PONDS 0 I hereby certify that I have prepared this application and that the work wilt 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." Contractors hiring or sub-contracting signature certifies the following: "I certify thit 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 t call f req" ired inspections. Complete drawing on reverse s' a Signed X Title: • _ Dater FO DEPARTMENT USE ONLY AppNcation Accepted by ____ .•� n.a,�11f:► _ pate �� .1 Area 2-� Pit or Grout Inspection by Date Final Inspection by Dat, 7S,*0 Additional Comments: Applicant -'Retuin all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services { 1601 E. Razelton Ave., P 0 Box 2009, Stockton, CA 95201FIEE INFO 'AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 8Y PATE PERMIT"N0. -'EM 1724 IPEV,I/N SI .^� 1 EH 14.28 �0 0 - a.