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i APPLICATION FOR PERMIT SAN JOAQUIN COUNTY -PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 95201 PFsR1fTT EXPIRES 1 YEAR-FROM DATE I§SUED. (Complete in Triplicate) t Application Is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application 1s 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. , ,l(/,,� �, i Job Address y City S C 445"'o--Lot Size/Acreage Owner's Name Cra ^f �.4 C .± Address Phone tr 9 2_ Phone r Contractor el-016-�� o� Address �• � r W`{ Vr.l �License No. YJ(g IT TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl out of Service Well ❑ PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C-1 Industrial ❑ Open Bottom C# Manteca Dia. of Weld Excavation Dia. of Well Casing Ca Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'l Public 1-1 Other 177 Delta Depth of Grout Seal Type of Grout -- I I Irtigation Approx. Depth l I Eastern Surface Seal Installed by Repair Work pone O Type of Pump H.P, State Work Done_ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material &Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I JNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence A!'– Commercial_ Other Number of living units: Number of bedrooms S Character of soil to a depth of 3 feet: Water table depth G No. Compartments SEPTIC TANK. 13Type/Mfg Capacity.—. PKG. TREATMENT PLT. Cl Method of Disposal Distance to nearest: Well foundation Property Line LEACHING LINE No. & Length of lines Total length/size YC. Y a –,4 3 FILTER BED 0 Distance to nearest: Well 46!C�?r Foundation Property Line &Lr � SEEPAGE PITS 11 Depth .St _Size_3 — Number SUMPS D 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 certify that in the performance of the work for which this permit is issued, l 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: Date: FO EPAR ENT USE ONLY Application Accepted by Data as Pii r Grout inspection by Date Final Inspection by Date�f I 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 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED By DATE PERMIT NO. INFO CASH . EH 13-A IREV.IihsS 420 EH 9 —7Q .Qu 10.1bJ , t -;