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I, APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL ;HEALTH DIVISION 1601 E.IHAZELTON AVE. ,..-PHONE (209)468-3420 I P O,BO% 2009, STOCKTON, CA 95201 r I IEXPIIES i YEAR FROM DATE ,XSSUID (Complete in Triplicate) Application in hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in c 4liance with San Joaquin County Ordinance No. 549 and 1862 and the Mules and Regulations of San Joaquin County Public Health Services. � ill Job Address 0 /✓, DX 4,11S ,2D City S7-&Al Lot Size/Acreage Owner's Name 13 EEC -P,-& DPM E.✓ Address 3 11 q tri, 14 g Lit/ Phone •-e, Contractor �`OY'l> eg][/JDo_Z2 Address 7 e!et License No. Phone r 97� TYPE OF WELL/PUMP: ��. NEW WELL Q WELL REPLACEMENT ❑ DESTRUCTION (} Out oP Service Well ❑ I i PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER ❑ Monitoring Well ❑ I 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 E] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C] Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'I Public l i Oiher i-] Delta Depth of Grout Seal Type of Grout-e,` I I Irrigation 'II'A I �. pprox. Depth I 1 Eastern Surface Serif Installed by Repair Work Done U Typelof Pump H.P. s ,f State Work Done._._ Well Destruction ❑ Well Diameter Sealing Material & Depth I Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION ! I (No septic system permitted if public sewer is LO available within 200 feet.) Installation will serve: Resrd ICommercial— Other Number of living units: Number of bedrooms Character}of soil to a depth o`?'3 feet: ¢ u Water table depth SEPTIC TANK ❑,. Type/Mfg Capacity``,l�o.o No. Compartments PKG. TREATMENT PLT.❑ �` :.. ." 4. g Method of Disposal Distance to nearest: Well undation " property Line LEACHING LINE No. & Length of lines 'L -- as'` Total length/size 74' FILTER BED ❑ Distance to nearest: Well a✓o4` 'Foundation __ I r Property Line k SEEPAGE PITS Gid Depth 5ixs Number SUMPS { CI Distance to nearest: Well /,ear Foundation lv0 ` Property Line zoot DISPOSAL` ONDS `` ❑ ��. Y I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state , rules and regulations of the San 'Joaquin County laws, and 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 anylperson in-such manner as to become subject to workman''s compensation laws of California." Contractor's hiring or sub-contracting signature i er11 les the;followr g:"I certify'that. in.the.performance of the work fol which this permit is issued, I shall employ.persons subject to.workman=s-compensa- t The pptiicarlt must call for allrequired inspections. Complete drawing on reverse side. Signed X Tide: Date: ' x • "1.t. FOR DEPARTMENT USE ONLY Application Acceptei �by �' •-� e� 2-1 r DArea Date Pit or GroutlInspection by # Date Final Inspection by Date 7 I t Additions! Comments: 4 _ Applicant I(- Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services ` 1 1601 E. Hazelton Ave., P 0 Box 200 Stockton, CA 9. 95201 FEE INFO ;AMOUNT!'DUE AMOUNT REMITTED CA$H RECEIVED 8Y DAT) PERMI7'N0.EM 13-21(REV.ti n 51 t � ©b EH 14-Ze ! ``- 3o3q 1 5 q IS* IN