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APPLICATION FOR PERMIT rr � SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES lJ ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOR 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. -Lea Job Address 3 Sol ✓~ Aus -h h City ( Q Lot Size/Acreage ` Owner's Name Gar i sh er Address 2 3 t/ S- Phone r 2A71 •Contractor Nix rho u Address kee /wail 04k License No. hone �u TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER O Monitoring Well C3 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS s- n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 14 Domestic/Private JLGravel Pack ❑ Tracy Type of Casing ^ Specifications — ("I Public (-1 Other n Delta Depth of Grout Seal &40 Type of Grout I I Irrigation Approx. Depth ►I I Eastern /Syrface Seal Installed by Repair Work Done D Type of Pump sub-m- H.P. b djZ State Work Done_ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filer Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1 1 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 SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal + Distance to nearest: Well Foundation Property Line LEACHING LINE CI No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to.nearest: Well Foundation Property Line DISPOSAL PONDS ❑ s 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 Californ The applicant u call,for all required ° spection omplete drawi on reverse fs�ide. Signed X tie: — gen . mq f Date: FO DEPARTMENT USE ONLY Application Accepted by 11 11 Date� 2^ Area Pit or Grout Inspection by wte Z 'S Final Inspection bv. Data�� - c � Additio9aI Comm�'ts: Applicant - eturn cope to: San Joaquin County blic Hea t �Q>'x� 12 fo / Services, Environmental Health Permit/ServicesC/'7 la z 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH CK 0 RECEIVED BY D R` PERMI7'NO. + EN ..262/1REV.iir+slAEH°II0_ 4 .Ofd 13'q MR a ,qI / UrzeCJ X44 °�Jv.w V✓� f f�- r;c-..f. 6,11,,,d C,,