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II APPLICATION FOR PERMIT � J � i f .!I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. PHONE (209)468-3420 ,• —✓ ;e P O BOA 2009, STOCKTON, CA 95201 Ii RTMIT EXPIRES„1 YEAR FROM DATE ISSUED (Complete in Triplicate) it Application 1s 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 RegulationB of San Joaquin County Public Health Services. t Job Address City_y I (} , /� } .� City Lod_A� Lot Size/Acreage Owner's Name 1 Address _ 0 -O 2r �. � �� Phone �w I Contractorv, l l In Address License N Phone!&_t,;l_779 TYPE OF WELL/PUMP; NEW WELL ) WELL REPLACEMENT ❑ _ DESTRUCTION 0 Out of Service Well PUMP INSTALL4TION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Weil R F DISTANCE TO NEAREST:-SEPTIC TANK-`- 0� - _SEWER LINES, DISPOSAL FLD. PROP: LINE/SO If - _FOUNDATION AGRICULTURE WELL ` _ -OTHER WELL PITS/SUMPS I l INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI NS J! I F] Industrial Ops- Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I , ,Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing�Ce Specifications I"i Public C] Otter ❑ Delta Depth of Grout Seal , - t -T p o�Grout[ >~Itti�n r l I IDation � Approx. Depth I I Eastern Surface Seal Installed by s vti Repair Work Done L3 Type of Pump„;", H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth ' Depth Filler Material & Depths TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 II REPAIR/ADDITION I I DESTRUCTION I I" (No—septic system permitted if public sewer is C I, available within 200 feet.) _4 Installation will serve: Residence_ Commercial— Other {. Number of living units: Number of bedrooms i +. Character of soil to a depth of 3 feet: Water table depth ! ISEPTIC TANK ❑ dType/Mfg Capacity No: Compartments IPKG. TREATMENT PLT. ❑ I, Method of Disposal Distance to nearest: Well Foundation Property -.Line LEACHING LINE ❑ No. & Length of lines Total length/size" I FILTER BED L7 Distance to nearest: Well Foundation -Property-Line- - #SEEPAGE PITS 1 I Depth Size ' ' Number SUMPS LI Distance to nearest: Well Foundation a DISPOSAL PONDS Cl ii Property Line I hereby certify that ! 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;'l shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contractinfl 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-workrlaan's compensa- tion laws bf Calif6rnla." - - The applicant must call for all required inspections. Complete drawing on reverse side, Signed Title: C Date: OR DEPARTMENT USE ONLY Application Accepted byIA -a �� o 2 Date Area Pit or Grou Inspection by D t Final Inspection by ate ii Additional Comments: ,w Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services k I! 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUEAMOUNT REMITTED CK INFO CASH RECEIVED BY DATE PERMIT'NO. I EIS 13-24 IREV. EH 21.29 105, r o—o r��I }) �] 46 • '1 �C�