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{ APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES '4 x4,i ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 SMAY,7 P O BOX 2009, STOCKTON, CA 95201 �, PUgNM JO,4 I,. l PERMIT EXPIRES 1 YEAR FROM DATE ISSUED VIRa��E T�AHE EUU Ty l (Complete in Triplicate) - Application riplicate)Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Pu 1th Job Address a, a°fp";)City Lot Size/Acreage I f Owner's Name ' ""`""� � Address Phone 46r 0/ Contractor �ra��'r� Address315�' �uStlA S �1r• ;LiCV�en�se No,--mot_ . Phone -&Z W 9 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION D SYSTEM REPAIR ❑ OTHER V�Zrwif, ill f7 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 3 1)6& 17*oW'1114OW Ll industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing * Domestic/Private ❑ Gravel Pack Ll Tracy Type of Casing Specifications I.} Public Cl Other 11 Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done_ O Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth ? TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I 1 DESTRUCTION I 1 INo septic system permitted if public Sower 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/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal 1� Distance to nearest: Well f=oundation Property Line 1 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line r SEEPAGE PITS 1 1 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 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 Californ' The applicant mus a for all required inspections. Complete drawing on reverse side, Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by ' Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: A Applicant — Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services i1601 E. Razelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE+ INFO AMOUNT DUE AMOUNT REMITTED CASH R VED BY DATE PERMIT NO. { . EH 13.24IREV.I/K5l /VV f ITV �0011 7 �' w EHi4-2e i