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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES t ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468--3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT 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 trade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. f� Job Address 67-74 City ��/� Lot Size/Acreage /do _ Owner's Name ,IO�. { - --- Address A /�� Phone Contractor l� ,l.r.�- Address !J dam! l �� License No.17-23fY PrionX3 - `79 Z i TYPE Of WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATIOf�6 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation .E Dia. ol`.W, Casing 0 YDomestic/Private Gravel Pack ❑ Tracy Type of Casing w Specifications- I'1 Public. 1-1 Other n Delta Depth of Grout Seal _/ Type of GroutCCem-et- , I Irrigation L00—..Approx. Depth I I Eastern Surface Seal Installed by Repair Work pone_ U Type of PumpS7�� H,P, State Work pone _AMA aA Well Destruction .0 Well Diameter Sealing Material S Depth ; "' Depth Filler Material 3 Depth R O TYPE OF SEPTIC WORK: °NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION I i iNo septic system permitted if public sewer is available within 200 feet) Installation will serve: Residence_ Commercial_ Other -Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth I SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PET. ❑ ' �� Method of Disposal Distance to nearest: Well Foundation Properly Line # LEACHING LINE Ll No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Propeny Line SEEPAGE PITS 11 Depth Size Number } SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 canify 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 l 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 applicant must call for all required inspections. Complete drawing on reverse side. Signed X__.- _- iCe._ Title: _Zl � Date: Data ) FOR DEP TMENT USE ONLY J �f App cation ccepted by Date_e r_2 2— r 6 Area r o3 y—r Grout spection by Date �a Final Inspection b - -30 --- - 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 95201FEE NYU` INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. . Ert13-24 ISMv i x 5) fCTO f V Ti] W ``G 2DLY0 ��5 l EM 7��7e ]