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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES Ij ENVIRONMENTAL HEALTH DIVISION X601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOR 2009, �STOCKTON, CA 95201 PER![I T EXPIRES 1 �IhYEAR FROM DATE ISSUED I� (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 1562 and the Rules and Regulations of San Joaquin County Public health Services. Joh Address /7ub1�� 2�Gk �D i`__— City $l- F� 49r� Lot Size/Acreage z /2- Owner's Nam�N: DG'✓/lJ ie�c"�f,,ess / Ale Phone X721 ddress _ -��16s License No. tETZ.2 Plione,�� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER p Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESI� DISPOSAL FLO, PROP. LINE FOUNDATION AGRICULTURE,WELL OTHER WELL PITS/SUMPS ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ,❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing TI Domestic/Private Cl Gravel Pack ! ❑ Tracy Type of Casing Specifications I"I Public {-1 Other-_ I .n Delta Depth of Grout Seal Type of Grout II I Irrigation __Approxi!Depth I I Eastern Surface Seal Installed by ;Repair Work Done 0 Type of Pump H.P. 'k State Work Done _ ;Wall Destruction ❑ Well Diameter Sealing Material & Depth I Depth Filler Material & Depthth SI`i I TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIR/ADDITION i I r DESTRUCTION I 1-`lNo septic system permitted if public sewer is 'iavailabie within 200 feet.l `Installation will serve: Residence_ommercial Other 1 Number of living units: l Number of bedrooms _ Character of sail to a depth of 3 fest:'� `r ater table depth SEPTIC TANK'' ❑ Type/Mfg capacity, o. Compartments PKG. TREATMENT PLT. ❑ it r- Method of Disposal Distance to nearest: T Well . _ Foundation� Property Line p iLEACHING LINE ° No. & Length of lines _� - +'�-Total length/size f `� a rltf�, FILTER BED �� ❑ Distance to nearest: Weil �� FoundatiorS'• Q F� Property Line II i ,. . i 'SEEPAGE PITS I Depth --Si,, �v� �� `" Number I _ !SUMPS Ll Distance to nearest: Wel/��Foundaiion � Property Line ' 75 '7DISPOSAL PONDS ❑ h I�. - 1 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 a ,Home owner or licensed agent's signature certifies the following: 1 cartJ that in the performance of the:work for which this permit is issued, I shall not 'employ any person in such manner as.tolbecome subject to workman's compensation laws of California." Contfactof'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 parsons subject to workman's compensa- ,uon laws of California." IN Jrevefse`The applicant Imu't call.fol all 'quired inspections. Complete drawing side.` Signed X Title: Date: 'FOR DEPARTMENT IfSE ONLY Application Accepted by Date Area ;Pit or Grout I Inspection by I� Date I' Final Inspection by Date .S f11 - I� Additional Comments: ._ I� Applicant Return all copies to: San Joaquin County Public Health Services, Environmental }Aealth.Permit/Services 1601 E. Hazelton Ave., PI�O Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMo.u4t,REMITT D „y.CASF1 RECEIVED BY DATE PERMIT_.NO,_. �i + EH 13.24 iREV.�/n sl INFO / h EH i4-26 - 11 - / -II