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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES _ r ENVIRONMENTAL HEALTH DIVISION ; > 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOR 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby msde.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 1862nd the Rules and Regulations of San Joaquin County Public Health Services. Job Address c Q /U 1 C 9 5,. 4:4vu2 City --6 %x1 //- Lot Size/Acreage Owner's N li,�i �`h.,-%i c�t %f�zl 'G-:Jfc Address Phonsn2/ -_;t2!- -`- / L Contractor "; iC�- �'�lt Addres � � 1 /6 =i ''� License No_�r�{�'C' t� Phoned =j {2 TYPE OF WELL/PUMP: NEW WELL 13WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well O PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O Monitoring Well 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 C7 Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �� Domestic/Private ❑ Gravel Pack Ll Tracy Type of Casing Specifications 0.. 1'1 Public Cl Other n Delta Depth of Grout Seal Type of Grout 1 1 Irrigation _.Approx. De`to I I Eastern S r) Seal Installed by Repair Work Done U Type of Pum H.P. � %- State Work Don Well Destruction O Well Diameter Sealing Material & Depth t Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other \1 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 Distance to nearest: Well _ Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size _ Number SUMPS Ll 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 C fornia." The applica must call for a l-required ins tions. Complete drawing on verse side. rL-`<" c J Signed 'Viz✓, Title: Date: FO DEPARTMENT USE ONLY p` q i ^� Application Accepted by Cn... n��„< < Date p _-k 1 - Area E3 f L-- Pit or Grout Inspection by Date Final Inspection by T _� �� 1_1__ -gate ^'�I 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 REMITTEDCA5H ECEIVED BY DATE PERMIT'N/O..11 /y . EH 13-24(REV.t/N5) k53sel EH;426 /V ld -