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4/ 776 i APPLICATION FOR PERMIT i SAN JOAQUIN COUNTY .PUBLIC HEALTH SERVICES t ENVIRONMENtAL`,JHEALTH DIVISION f 1601 E. HAZELTONWAVE., PHONE (209)46$-3420 P O SOX 2009, STOCKTON, CA 95201 EXPIRES 1 YEAR FR M DA E SD i (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 cotipliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin CountyPublic Health Services. Joh Address / �` �� City Size/Acreage 4 Sb 6S Own``er's.lName L-a2�.�I'�+1 `�_ address _ r��- I A _ Phone Gtint�actor Ge �+.� d _Address_ P6 �i ,� ` 2'�Y \W,-° License No �l�Phone z TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well PUMP INSTALLATION O SYSTEM REPAIR W1,01 OTHER ❑ Monitoring Well DISTANCE TD NEAREST/S'EPTIC TANK SEWER LINES DISPOSAL FLD, t PROP. LINE iFQUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE,/ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F] Industrial ❑iQpen Bottom ❑ Manteca Dia. of Well Excavation i Dia. of Well Casing fil�omestic/Private 0. Gravel Pack ❑-Tracy-"'"'"""'"Type of Casing � Specifications ['1 Public Cl Other fl Del a,(Z 1Dep.h of Grout Seal Type of Grout I I Irrigation �Approx. Depth t Eastern Isurface Seal Installed by k I t. !!! .�+ �� -�3 k � j State Work Donle N Repair Work Done j�`Yype of Pump I "H•P Well Destruction Well Dlimeter Sealing Material & Depth Depth Filler Material & Depth� f f ' 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.) i Installation will serve: Residence_ Commercial_ Other Number of living units: Number'of,bedrooms Character of soil to a depth of`3 feet,r:_a :X) Waier table depth ' Nof Compartments SEPTIC TANKI ❑ Typ1lMig Capacity P PKG. TREATMENT PLT. ❑ Method of Disposal (�'1 Distance to nearest: Well Foundation Property One , 1 1 r LEACHING LINE L-I No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line 6 3 { SEEPAGE PITS 11 Depth Size Number SUMPS."' -F L1 Distance to nearest: Well Foundation Property One DISPOSAL PONDS-0 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, andM rules and regulations of the San Joaquin County Home owner or lice age '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 per in ouch ner as to become subjec o workman's compensation laws of California."Contractor's hiring or subcontracting signature r certifies the f owing: "I cert' that in the pe or an the work for which this permit is issued, I shall employ persons subject to workman's compensa- f tie)n laws o Califor is. The appl- an mu o all req e p e drawing on r ide,�A Signed Titla: �`�f� Date: ^ 7 D [A`• T USE ONLY + Application Accepted by O Data Area Pit or Grout Inspection by Data Final Inspection by Date r 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 I AMOUNT UE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH ♦ EH13.24[REV,r/n 51 '-9{� O EH 74.26 - .;