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y� 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 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 vork herein described. This application is made in colnpliance:vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. �r� Job Address 66 City -sem Lot Size/Acreage �� 'S`"' r Owner's Name s �G �/y 17- Address Phone Contractor AddiessSOP License No.4 Tires_Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 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 D Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing F] Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications , I'} Public f-I Other 171 Delta Depth of Grout Seal r Type of Grout I i Irrigation _.Approx.'6epth,y Id-Easlernr Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done _ I" Well Destruction 0 Well Diameter Sealing Material & Depth U1 Depth Filler Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION FX REPAIR/ADDITION.I I DESTRUCTION I I iNo.septic.system permitted if public sewer is availablefwithin 200 feet,) , Installation will serve: Residence_k� Commercial— 'Other "° t V i Number of living units: _J_ Number of bedrooms-^'-��`---•---"- - -_—�—f'=�^��=t--��^��-----��•---�- { Character of soil to a depth of 3 feet: I _A n49,6:_ _ S_ Water table depth SEPTIC TANK. ❑ Type/Mfg 1. Capacity No. Compartments; PKG. TREATMENT PLT:CTE ifiµ I=G { Method of Disposal Distance to nearest: Well 16.d-t, ✓Foundation.`;�� Property Line >Gd/":' I i LEACHING LINE IE L No..,&•Length of lines 'fid' �..^` Total length/size /I'� e T rp FILTER BED .❑ Distance to nearest: Weii I qol'e�_�Foundation ' cx2 ef E Property Line , SEEPAGE PITS" } Depths Size f� ` '' Number SUMPS LI Distancelcoinearest: Well 24.522_7' Foundation '� Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application-ind that the work will be done in accordance with San Joaquin county ordinances, state laws, and i 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, I shall not employ any person in such manner as to bbcome 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 taws of California." j ,A The applicant must-call for all required inspections.-Complete drawing on reverse side. ; Signed X _ 1 /.,c Title: —gr r,e! -_--- _ .a, Date: F EPA ENT USE ONLY A lication Accepted by Date Area Pi r Grout Inspection by Date Final Inspection by Date 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 RAMOUNT-DUE. —AMOUNTRElV11TTED ^'' ECEIVED-BY——OATE" — YoPfRT_40: INFO" CASH + EH 1324(REV.t i K 51 Q EH 1�--26lC 'Fr S—