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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 f b�tRvrT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) i, 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 Co a Services V t S �b utlty�!b' f 23 r 6 0 AJ. b,4 Job Address kDFA��`IS ROAD 114 MILE MORTH' OF PELTIER City ACWQ Lot Size/Acreage Owner's Name PANELLAJARMS Address TONPhone - 5000 M 2( j-e,_> Contractor NO.,KK PLIMP } Address License No. 50451 Phone - 8817 TYPE OF WELL/PUMP: r.' NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well CA PUMP INSTALLATION C] SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r C] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing t Cl Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing —Specifications I"I Public l:] Other - n Delta Depth of Graut Seal Type of Grout V &rrigation —.Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done,_,P11L1 20FiP TLjRBINE PU C Welt Destruction ❑ Well Diameter Sealing Material & Depth ELL, Depth Filler Material b Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.1 Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms r Character of soil'to a depth of 3 feet: Water table depth SEPTIC TANK - ❑ Type/Mfg Capacity No. Compartments ' PKG. TREATMENT.PLT. ❑ ^� .. _ Method.of.Disposal. Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED CI Distance to nearest: Well Foundation Property Line, SEEPAGE PITS I 1 Depth Size Number M SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL'PONDS Cl 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 cenifies 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 C a " The applicant must call or all re it . Complete drawing on reverse side. ` �} e'�� RETAIL SALES /tl-Signed X DiTitle: Date: R DEPARTMENT USE ONLY �� >a Application Accepted by AL . � , - .. Date �� Area Pe Y P Y y-G�� � Pit or Grout Inspection b Date Final Inspection b �� Date 1-3-Sys Additional Comments: ` �-� a - - �� to �- �� ^e} �[�.� SQr 1324Q (4 �+a Applicant - Return all copies to: San Joaquin County Public Health � 1 Services, Environmental Health Permit/Services vu�'r_c�•-r„z.� _6�re 1601 E. Hazelton Ave., F 0 Box 2009, Stockton, CA 95201r- r � rd FEE AMOUNT OUE AMOUNT REMITTED CK 6 INFO CASH RECEIVED BY GATE ERMf O. /'. / t EH f3-24 IAEV,rirssj IY t EH:4.2b ! r 1 �i