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r A APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES T ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O 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 Be i es. ` Job Address �' + 1 City W�Lt Size/Acre e Owner's Name w • Address �� 7y'�/N E� Phone Contractor, VO4Aerress Q _lam G _License No.(_J/1k23&one 6(0— Z 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 Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1'I Public Cl Other n Delta Depth of Grout Seal Type of Grout W'lirigation —,Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of PumpS� H.P. _- 1S State Work Done Well Destruction ❑ Well Diameter Sealing Material.& Depth �J Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITI N 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 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 0 No. & Length of lines Total length/site FILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI 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 lic ant's signature cen f.a he following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any per n in suc manner a to beco s bject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the fo wing: "I rtif the h or ance of the work for which this permit is issued, I shall employ persona subjeot to workman's compensa- tion laws of alifornia." The applic t s for I r ctions omplete drawing*;e A` �,v >,(J Signed Title: Date: s FOR PARTMENT USE ONLY Application Accepted by t12V114 I Date (�. Area Pit or Grout Inspection b Date -_e�� Y final Inspection by� Date CJ 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 IEEE MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 13.24(REV. i n sl '_,�� �" /� l �� / J EH A-2e