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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 O BOX 2009, STOCKTON, CA 95201 a ow. 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 CountylPu7blic Health S^er,vi-ces.., Job Address ` r t � `^` � t"`L Citya_t4 't- Lot Size/Acreage 50_t rnn n 33y -cF--i`I b Owner's Name , V �^� '`r� `� �Y�x`�'�'� Address ' 08 VAT6- Phone y'9 j -9900 Contract�� r*""�� Address `L� e ��7 License No.J2-gz� cp Phone 5 WS TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 11 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C l Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I"I Public 1.1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation —,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 A 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` Commercial_ Other Number of living units: Number o bedrooms j Character of soil to a depth of 3 feet: 64eLN, Water table depth SEPTIC TANK `,q Type/Mfg Capacity �(pnC"� No. Compartments PKG. TREATMENT PLT. ❑ f r Method of Disposal Distance to nearest: Well �Q Foundation Property Line�_ N LEACHING LINE No. & Length of lines o Total length/size. r FILTER BED ❑ Distance to nearest: Well ©n, Foundation 115 Property Line a/ SEEPAGE PITS X Depth Size W OL i(lumber ,S SUMPS Cl Distance to nearest: Well–A-516- 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, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must I for all ire inspections. Complete drawing on reverse si e. Signed X Title: �e Date: o FOR DEPARTMENT USE ONLY Application Accepted by I Date �5_ .,- 115�C� Area OF" or Grout Inspection by Date Final Inspection by� s.,12�lDatSt 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 4 CASH RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV,t/Nsl /q- 40-4)44 EH it-28