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AVO O 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 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application 1s 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 AL. ,�r Job Address �SU ` 4LPINk 4eD. City 10&/aW Lot Size/Acreage Owner's Name �\�1'� CC'D r1C Address SA"I-%- Phone Contractor �� Address 1 .L7f' License Nos 0* 7.2/ Phone TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR O OTHER O Monitoring Well C3 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 n Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing C) Domestic/Private O Gravel Pack O Tracy Type of Casing Specifications Il Public i❑ Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _.Approx. Dept),, rI.Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction O Well Diameter Sealing Material & Depth Depth ,Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRYADMTION DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Cimmerciaf,. Other Number of living units: Number obedrooffis: s Character of soil to a depth of 3 feet: y ` Water table depth f SEPTIC TANK. O Type/Mfg >- Capacity � NoN.Compartments PKG. TREATMENT PLT.O �. Mefhoh Of Disposal Distance to nearest: Well ; Foundation Property'L-int. LEACHING LINE Ro"No. & Length of lines Total length/size S FILTER BED ❑ Distance to nearest: Well d2 00 Foundation 0/ Property Line . SEEPAGE PITS IV Depth JR a 340 Number SUMPS LI Distance to nearest: Well AaQ / Foundation .►f / •�� /cS Property Line ' DISPOSAL PONDS O 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, 1 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 applica call for all requi d i9spqctions. Complete drawing on reverse side. Signed X Title: l Jw Date: FOR DEPARTMENT USE ONLY Application Accepted by Date��---,Area p or Grout Ins y inspection b � Date � Final Inspection by Data (/ 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 INFO AMOUNT DUE AMOUNT REMITTED CASH CK J RECEIVED By / DATE PERMIT'NO. + EH 24(REV.S/ H5) 1tq-oo_4114-03 EHt/•