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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION KE1 S PUMP& WELL SERVi10E1601 E. HAZELTON AVE. , PHONE (209)468-3420 P.O.BOX 602 LINOEN, CA 95236 P O BOX 2009, STOCKTON, CA 95201 T.UC.#521666(209)9445969 PEMIT 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.� 19-a Job Address -D et a/jA a City Lot Size/Acreage Owner's Namer �y+d�°�+�`` Address m Phone Contrac4l(,`G 1C I Address License No-r&"—Phone TYPE OF WELL/PUMP: NEW WELL © WELL REPLACEMENT 0 DESTRUCTION 0 of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR OTHER D Monitoring Well U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL FLD; PROP. LINE �AGRfCU;LTUFiE WELD TO7HER WELL _PlTS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L] Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Weil Casing 71.Bomesiic/Private ❑ Gravel Pack L] Tracy Type of Casing Specifications I'f Public Cl Other f-1 Delta Depth of Grout Seal - rout I I.Ir'tigation _Approx. Dep I # Eastern CSurface Seal Installed by I " q Repair Work Done LJ Type of Pump H.P. �yJ Sta ark Done Well Destruction 0 Well Diam'ter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I INo septic syste rmitted if public sewer is LIN 1 able within 200 feet.I 1urw, Installation will serve: Residence_ Commercial_ Other Mks H jl rH Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: .. ( Water table depth SEPTIC TANK 0 Type/Mfg ' Capacity No. Compartments PK G. TREATMENT PLT. ❑ Method of Disposal ' Distance to nearest: Well foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED 11 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth 1 Size T _Number SUMPS Ll Distance to nearest: Well Foundation f Property Line DISPOSAL PONDS - —^..«e._'�_8a..-"'. ` �- --..�.. •w 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 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: "$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 II for all requir i spec 'ons. C mplete drawing on reverse 'de. Signed X .Title: Date: I OR DEPARTMENT USE ONLY r Application Accepted by 4X -Li 04 2A ti AOCA�=a, Date Area Pit or Grout lnspectionlby f Date Final Inspection by . _,,., DatefU� Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health ' I Services, Environmental Health Permit/Services ` 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'N0. EH 13-24 IREv.;/x sf EH 14-20 "V� ('�f'�J r,'$ irf� �•