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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 REMIT EMIRES. 1 YEAR FRQM DATE ED (Complete in Triplicate) + Application is hereby [[lade 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. `_ }4 _ Job Address City' ^ + Lot Size/Acreage &KA.L. t � 1 r�I`_ R Owner's Nameic- 0 Address y y �� ,1�'Phone i � t ! Contractor Address 3s- ` G11 License No.2fPhone TYPE OF WELL/PUMP: NEW WELL LJ WELL REPLACEMENT D_ DESTRUCTION Out of Service Well ❑ PUMP INSTALLATION ❑ 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 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack El Tracy Type of Casing Specifications I1 Public Cl Other Fl Delta Depth of Grout Seat Type of Grout I I Irrigation 3t?�d_Approx.;Depth I Y Eastern Surface-SeaI•inst-al led by-'"`" Repair Work Done (3:, Type of Pump H.P. State Work Done f Well Destruction R Well Diameter _ f Sealing l+laterial & Depth 1 r , , cy `.Depth -W&D Sam Filler Material & Depth V wt u TYPE OF SEPTIC WORK: `NEW INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION I I lNo septic system permitted if public sewer is / i i available within 200 feet.) Installation will serve: Residence_ Commercial Other - { } r Number of living units: Number of bedrooms ,. Character of soil to a depth of 3 feet: ' -Water table depth SEPTIC TANK. ❑ TypelMfg k- Capacity No. Compartments E PKG, TREATMENT PLT.❑ f' Method of Disposal Distance to nearest: Well - Foundation :Property Line LEACHING LINE D No. & Length of lines Total length/size FILTER BED C1 Distance to nearest: Well Foundation Property 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 4 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: "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 Title: Q�aaarAn,�. --- Date: 23- 1 R'DEEPPARTM.ENT USE ONLY Application Accepted by _coil - �^ + ----- Date '� q� `1� Area Pit or Grout Inspection by Date Final Inspection by Date 21 1 S Additional Comments: v Coif r rGa u o'E- d r Applicant - Return all copies to: San Joaquin County Pu lic Health Services, Environmental Health Permit/Services I i 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO �� ']-7 c `� . EH 13-14 iREV.t/n51 cy� Q.C1 V l C�CJ l EH i4�3e ---- 1