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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 work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health'Ser/viicess.. Job Address ` 7 /� `� y �- -- City C Lot Size/Acreage AD Owner'a Name O!f«"/ dress Phone Contractor !\ �7V -� Address04536&1 7a ____ License No-22945 -Phone33 V 92 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT D DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATIO SYSTEM REPAIR C1 OTH�R ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK ZOO SEWER LINES DISPOSAL FLD.,/-Sa PROP. LINE L10 FOUNDATION AGRICULTURE WELL OTHER WELLi PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Indus ❑ Open Bottom O Manteca Dia. of Well Excavation /Z Dia. of Well Casing D st"/Private )[Gravel Pack 0 Tracy Type of Casing � G-- ____--___ Specifications Cl ublic f 1 Other f) Detta Depth of Grout Seal x.20 Type of Grout__-1t'{/1L!/�1 154 Irrigation _.Approx, Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. -L- State Work Done Q 4!Ll X Well Destruction ❑ Weil Diameter Sealing YAtekalX Depth �} Depth Filler Material & Depth , TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms 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 n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll 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, 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 c6mpensa- tion laws of California." Sig nedpxcant must Fall for all required inspections. Complete drawing on reverse side. !/ZJ,L/��/ Signed _ _ Title: Date: FOR f7EPA TMENT USE ONLY Applicatl! Accepted by Date — oArea IF Pit spection by Date I"2QFinal Inspection by4La (� 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 INFO AMOUNT DK A UE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. . EH 13-N 1REY.tins) S, cro e2r Cl,t