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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES j ENVIRONMENTAL HEALTH DIVISION � 1601 E. HAZELTON AVE. , PHONE (209)4683420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISS BP (Complete in Triplicate) I ' 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 cotlopliance!with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public 42— P"ubbl`ic Health Services. 4J Job Address 0 E ZA)if— Z City gTkl'l Lot Size/Acreage p� I Owner's Name ALLOO 7©�x/1j//Si/a� - Address Afu) Phone L Contractor 61CCO V Address f'2t1�AJ T License No � Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well C� 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: n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing D Domestic/Private Cl Gravel Pack L1 Tracy Type of Casing Specifications 1'i Public 1-1 Other L-4 Delta Depth of Grout Seal Type of Grout •Irrigation — Approx. Depth I I Eastern Jiurface Seal Installed by n Repair Work Done )C Type of Pump re6L6L15 H.P. k2O State Work Done Wel! Destruction ❑ Well Diameter Sealing Material & Depth ,C7 _(�4A A,7 Depth Filler Material & Depth " TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION I i iNo septic system permitted if 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/Mfgt Capacity No; Compartments PKG, TREATMENT PLT.❑ k + Method,of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ~L] No. & Length of lines Total length/size tit FILTER BED 0 ,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 Joaquiri 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 applicant must call for all required inspectio , Complete drawing o ver a side. Signed Xnt4 41A. Title: . 5-J� ; Date: ~ FOR DEPARTMENT USE ONLY C� Application Accepted by � — -- Date INr f Area Pit or Grout Inspection by Date Final Inspection by Date 4 F 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 AMOUNT DUE AMOUNT REMITTED CR If RECEIVED BY DATE PERMIT'NO. INFO CASH . EH 13.24IREV.1/K5 EH 1428