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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 2FaMIT 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 1662 and the Rules and Regulations of San Joaquin County Public Health Services. / /� 1 900 ar ). �I! �.�. Lot Size/Acreage(DJ 7 x 333 Job Address ,,� City Owner's Nameu � .t.�'►^ Address r b!�"St±o,� Contract s Address�P, License No. �-O�Z� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well [3 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 f7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 11 Domestic I Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications. ["I Public Cl Other rl Delta Depth of Grout Seal Type of Grout i i Irrigation ,Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material A Depth Depth Filler Material A Depth 0 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I 1 iNo septic system permitted if public sewer is L- .0/ available within 200 feet.) I Installation will serve: Resiience Commercial ther I Number of living units: f Number droom - Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. Type/Mfg Capacity IEL40—OVNo. Compartments PKG. TREATMENT PLT. ❑ , / Method of Disposal Distance to nearest: Well 50 Foundation .J� Property Line / / LEACHING LINE XNo. & Length of lines — Tgtal length/size tao X v� FILTER BED ❑ Distance to nearest: Well_ vn� _ Foundation tb Property Line _S0, SEEPAGE PITS Depth Size G Number SUMPS LI Distance to nearest: Well �._�+Q Foundation �O 1 _ Property Line 5 + 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 compensa- tion laws of California." The applic st call for q d inspections. Complete drawing on reverse s Signed Title: ___ _ Date: FOR DEPARTMENT USE ONLY Application Accepted by J Date 7+ 792=4Z2 Area I2� 4 or Grout Inspection by Date r ?' Final Inspection by 'L�C, Date �2 Additional Comments: _ J Applicant - Return all copies to: San Joaquin County Public Health ^.f Services, Environmental Health Permit/Services 1601 E. Razelton Ave., P 0 Box 2009, Stockton, CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY PATE PERMIT-NO. O . EM 13.241AEV.rin5i / EM;414 r r !J22 ZZ 21