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e' APPLICATION FOR PERMIT C F IP SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESREE V , ENVIRONMENTAL HEALTH DIVISION : 1601 E. HAZELTON AVE. , PHONE (209)468--3420 P O BOX 2009, STOCKTON, CA 95201 AUG 28 +"110 PERMIT EXPIRES 1 YEAR_FRPM DAIR Igi JSC IyD' ENVIRONMENT ` K �� (Complete in Triplicate) PERNMITi 4r MCES 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 / City Lot Size/Acreage Own is am �� Address Phone t7� ont c o ..`qtr AIIA {AS ; �C! icense No. /� Phone 6 I TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ Out of Service Well Cl PUMP INSTAL SYSTEM REPAI OTHER CI Monitoring Well C3 DISTANCE TO.NEAREST:_SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, UNE --FOUNDATION_ AGRICULTURE WELL OTHER WELL PITS/SUMPS F Y INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ' estic/Private CI Gravel Pack ❑ Tracy Type of Casing Specifications Cl Public CI Other n Delta Depth of Grout Seal Type of Grout # I f Irrigation �.Appra><, De I Eastern Surface Seal Installed b r , Repair Work Done EJ Type of Pump�• W.P.I S alqkg or o e Well Destruction ❑ Well Diamet Sealing Material 6 Depth I ew ;�,� Depth Filler Material 8 Depth O/" TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I 1 DESTRUCTION I I (No 'septic system permitted if public sewer is s ° available within 200 feet.1 f Installation vn'll server-Residence"_Commercial_ Other fl Number of living units:, Number of bedrooms r Character•of soil to a depth of 3 feel: t Water`table depth SEPTIC T, NK r 0--Type/Mfg j Capacity No. Compartments PKG. TREATMENT PLT. Cl `�, ' _ i. Method of Disposal •Distance to nearest: Well Foundation Property.Line LEACHING-UI E Cl _eVo,:& Length!of lines _ Total fengthlsire FILTER BED i r ❑ Distance to nearest: Well Foundation, . s , Property Line SEEPAGE PITS I I Depth Size Number I _4 SUMPS CI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS " - ❑' - -- -. -.— - � ��..,— �.�.r..--f � �..,.» -- R 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 t rules and regulations of the San Joaquin County ' Home owner or licensed agent's signature certifies the following: "f certify that in the performance of the work for which this permit is issued, I shall not f employ any person in such manner as to become subject to workman's compensation laws of California." Contractors 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 cAmpensa- tion laws of California." t The applica gust callor r uire inspections. Cmplete drawing on re rse sid C7 Sig d r Title• Date: QR DEPARTMENT USE ONLYc. /J 1 Application Accepted by Date ��&�o Area 21( { Pit or Grout Inspection by Data Final Inspection by `, 1 -� 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CK i CASH RECEIVED ay DATE PERMIT'NO. 4 . EH 13"24 INEV.I/a 5 - 2 1, yl EH.4.26 31 C7 o �32b