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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZFLTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PER 11 EMIRES 1 YEAR FROM DATE ISSUED (Complete iu 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 Services. Job Address 1 -7463 -5 , F A`-p rprLs-e, City E-"�Za4_ Lot Size/Acreage n Earl �4+off - — Address 16�Q� /lfr2" t i�j4d��&In P� a q2" 4V9� Owner's Name y� �,�d per— j�,, � � Phone (j Contractor. I� g ht Nme �"Y dress __�? �`'G� �� _ License tra, o Phone—90-6, 6, TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION REPAIR © OTHER ❑ Monitoring Well ❑ 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 . Sl C 1 Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation tt Dia. of Well Casing ` C*Domestic/Private Gravel Pack LJ Tracy— Type of Casing —Specifications I') Public I-1 Other [I Delta s Depth of Grout Seal Type of Grout fti 1 i Irrigation __.Approz. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of.Pump. H.P. State Work Done — Welt Destruction ❑ Well Diameter Sealing Material 8 Depth Depth t 1J— Filier,Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION l I INo septic system permitted it public sewer is available within 200 feet.) �} Installation will serve: Residence).._..._ Commercial_ Other f �� art. !rl Number of living units: _ Number of bedrooms 1 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, C] Method of Disposal :f Distance to nearest: Well Foundation Property Line rte, LEACHING UNE ❑ No. & Length of lines Total length/size FILTER BED C7 "fDistance to nearest: Well Foundation Property Line SEEPAGE PITS 11 +r Depth• Size Number SUMPS LI ,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''bounty ordinances, state taws, 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 Kiring or sub-contracting signature certifies the following: "I certify that in the performance of,the work for•whidh this permii:-:rs issued, I shall employ persons'subject to workman's compensa- tion laws of California," The applicag mt` t call for all reluiradi1) omplete drawin on reverse side. �� l Signed X to: Date: �J Q DEPARTMENT USE ONLY A Application Accepted by Date 4 Area Pit or Grout Inspection by Final Inspection b 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 +INFO AMOUNT DUE AMOUNT REMITTED I CASH RECEIVED BY DATE PERM17-NO. . EH 13-21[REv.1/K51 W� LJ� .( n .I[i '_U I EH 942E ►►VV `-� a qIi_D_ffB i