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r~' 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 IT EXPIRES 1 YEAR FR M DATE ISSUED �� ///� �Juin Complete in Triplicate)Application is hereby ma3e o County for a permit to construct and/or install the work herein described. This application in made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Jab Address City L_J� Lot Size/Acreage ' _ ] Owner's Name�t_ - Address�5+ J Phon Contractor)` Lr Address's/of �d �/�5�J-) ,. 1Y1_!.License No,� Phone 1 ` f � - TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT'D "DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION C1SYSTEM REPAIR L""F; i OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES .� DISPOS t;FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS k ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 4 Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing - ---- k : Specifications FI Public l:3_Other-- f�-Delta" ` depth of Grout Sea] ;Type of Grout I I Irrigation —.Approx. Depth € I Eastern Surface Seal lnstalfed by M Repair Work Done ❑ Type of Pump— H.P. State Work..Done_ Well Destruction ❑ Well Diameter Sealing Material Depth Depth Filler"Material'A Depthr + TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION l 1 DESTRUCTION I 1 INo septic system permitted if public sewer is availab!3 within 200 feet.! i 1 Installation will serve: Residence— 'Commercial- Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ;Z.5/ater table depth j SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Cl Method,of Disposal Distance to nearest: Well Foundation Property Line M i31) LEACHING LINE ❑ No. & Length of lines Total length/size r FILTER BED ❑ Distance to nearest: Wel! Foundation Property Line SEEPAGE PITS it Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line 1 DISPOSAL PONDS ❑ --�' 1 I hereby certify that I have prepared this application and that the work will be done in accordance with'San Joaquin county ordVances, state laws, and""7 rules and regulations of the San Joaquin County 7 1 �._ t t } 1. N Home owner or licensed..agenYs•signature certifies-the foilowing: "I certify that iri thb-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: '9 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." TheaDate:pplican mu call for requi a inspections.-Complete drawing onnrrevverrsef�sidde. �] f Signed X Title: . X p�-1 c � rC;Ic� ! G R PART ENT`USE ONLY �}C _ F 12— Application Accepted by Date �`—u Area n k Pit or Grout Inspection by Date Final Inspection.by atey � ' Additional Comments: Applicant — Return all copies to: San Joaquin County Public Health 1 Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, GA 95201 FEE A OUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0. INFO CXI . EM13-24(REV.1/wSI �[ VDlqcrd� �bg0 U EH 14-26