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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOR 2009, STOCKTON, CA 95201 J PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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. Job Address=°�� 3�-,'� l^^ �� ' Q City � Lot Size/Acreage Owner's Name AddressQ Q JL , t_1.CCL�i fes" Ill, Phone ContractoN � 0 CIL) Address EQ,E,&-&-1 0 ,XC*� License No.37� L�cO Phone 3�� S TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 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 C..7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public 1-1 Other fl Delta Depth of Grout Seal Type of Grout I I Irri47ation _.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence K Commercial_ Other Number of living units: ./ Number of b-adrooins � Character of soil to a depth of 3 feet: Water table depth �1 SEPTIC TANK Type/Mfg Capacity_ No. Compartments PKG. TREATMENT PLT. ❑ / i Method of DiPosal Distance to nearest: Well So Foundation d® Property Line f 9 r LEACHING LINE No. & Length of lines CS1 L4 b Total length/size X FILTER BED 0 Distance to nearest: Well es } Foundation cQ 0t4 Property Line SEEPAGE PITS Depth 015 Size �� Dumber SUMPS LI Distance to nearest: Well QQ° Foundation QQ fi Property Line DISPOSAL PONDS ❑ 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 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: "1 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 st call for� required insPections. Complete drawing on reverse srd Signed K Title: c F Date: r FOR D ARTMENT USE ONLY Q Application Accepted by Date � � ?1J Area Z_Z— Jt or Grout Ins ��9 ,P Inspection by / 'ate � C� Final Inspection by Date - C 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 95201FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK J RECEIVED BY DATE PERMI7'N0. + EH 13.211NEV.Iir+sr 1 EH:1.26