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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES f' \ ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 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. �y� Job Address ! ( � �J"al n c W City IfC-001�� Lot Size/Acreage Owner's Name _/ C-�`t'19 Ma1) Address !L> Phone 36 - Contractor J4 �`� -� St'M> Address 4412 - f'� 5 f License No. 31`� Phone_? TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION q0ut of Service Well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ ' w e�(.� OTHER ❑ Monitoring Well [7 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 El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing [I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i'1 Public 1-1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth 1 I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction l� Well Diameter IOj"` ` Sealing Material k Depth y,S f;� /C 1,-JQC �t r-R 7c'?�t%✓ '�' r_ Depth -©1f Filler Material & Depth r � TYPE OF SEPTIC WORK: NEW INSTALLATION ( 1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other ; Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth cam' SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line r " LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED C1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size _ Number SUMPS LI Distance to nearest: Well Foundation 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: "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 California." The applicant must call for all requi ad 'Inspections. Complete drawing on revere/side Signed X xlf ¢- Title: D4,cl ""f Date: FOR DEPARTMENT USE ONLY Application Accepted by C. ��{��e Date Area �— Pit or Grout Inspection by Date Final Inspection by -!i`, � 15� 1Date 4, /<P-6 Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health n Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED �K RECEIVED BY DATE PERMIT NO. . EM 13-24(REV.i/Ns) EM A-2e