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i APPLICATION FOR PERMIT SCANNED SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES � � I 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 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/Services. . , Job Address �� A-/)% 7(/ rlZ City!G/ct�ee.We ^'/Lot Size/Acreage Owner's Name L I/, /UI? Address Phone Contractor .L.� 4-1 L/�=-�i� Address ,f 0, /y% ItLL'F)_ License No.,2' -� Phone`--T TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I I Domestic/Private - ❑ Gravel Pack _❑ Tracy Type of Casing Specifications I'I Public FI Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by (` Repair Work Done U Type of Pump 1` H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATIONTit REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is rK \ available within 200 feet.) Installation will serve: Residence ii� Commercial_ Other Number of living units: _�„ Number of.bedrooms Character of soil to a depth of 3 feet: ,[�.4� �/ a-�'(� �A� Water table depth SEPTIC TANK ❑ Type/Mfg 4491, Capacity Z:2-oaLNo. Compartments � PKG. TREATMENT PLL ❑ — I Method of Disposal Distance to nearest: WeIPI- Foundations Property Line �- rT LEACHING LINE ;LIQ No. 8 Length of lines 40 Total length/size o k7l- FILTER BED rl 6istance to nearest: W jr�.Q t- Foundation ,5 'fr Property Line SEEPAGE PITS 11 Depth /o T T_ Size )(/brX /U1 Number _ SUMPS ;A Distance to nearest: Well I Foundation 7SFT 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, 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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant mustcall for required inspections. Complete drawing on reverse side. n Signed X Title: Dale: FOR DEPARTMENT USE ONLY Application Accepted by r(, / //_ � Date y� Area Pit or Grout Inspection by Date F nel Inspection by Data Z Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Stvironmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED C Sif H RECEIVED BY DATE PERM17N0. . EN 1124 IREV.vxm EH A 26