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APPLICATION FOR PERMIT Fn% E ,, SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 J U L 19 ISP P 0 BOX 2009, STOCKTON, CA 95201 ENVIRONMENTAL. HEALTH PERMIT EXPIRES 1 YEAR FROM DATE IS5UM PERMIT/SERVICES (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 Services. t Job Address �s 1" \ !�u of Size/Acreage r Owner's Na Address 6ZF4 hone 0 0 _dd l ic�eo.:34 � Phon� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION D Out of Service Well ❑ PUMP INSTALLATIOf� SYSTEM REPAIR 0 OTIHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing pomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public D Other n Delta Depth of Grout Seal J Type of Grout I i Irrigation _ Approx. Dej* I ) Eastern urface Seal Installed by t Repair Work Done 0 Type of Pump H.P. State Work Doa _ Well Destruction ❑ Well Diameter Ir Sealing Material & Depth E Depth Filler Material & Depth i TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION l I DESTRUCTION I I INo septisystem permitted if public sewer is available Eithin 200 feet.) �l Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Wa or table depth SEPTIC TANK ❑ Type/Mfg Capacity�' "` No.�Compartments , PKG. TREATMENT PLT. ❑ Method.of Disposal Distance to nearest: Well Foundation€ Property ane n LEACHING LINE ❑ No. & Length of lines _ 1 Total length/size I FILTER BED ❑ Distance to nearest: Well Foundation Property Line r f 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." Contfactor'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 Tt call for all re uired inspeptions. Complete drawing on rev a side. Signe v liQ � s' Title: Date: —Z t FOR DEPARTMENT USE ONLY 7� ;�j Application Accepted by _. _ Date v' L Area z'J Pit or Grout Inspection by Date Final Inspection b Date 3 5 Additional Comments: Applicant Return all copies to: San Joaquin County Public Health ter{ Services, Environmental Health Permit/Services / 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO OUNT OUE A NT REMITTED C KSH RECEIVED BY DATE PERMIT N0. ♦ E "A-2i 111EV.t�>+Si EHH ZI-2E lJ