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-APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 I _ P O BOX 2009, STOCKTON, CA 95201 J ,PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ,~ Application is hereby made to San Joaquin County for a permit to conatruct•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 s Joaquin County Public Health Services. t n2 3 Job Address ( `—�� t� ' City ' TG Lot Size/Acreage { j T Owner's Name"' FDzoJiS— -AddPess J ti ----� S" � Pfsone - Contractor ,� _(1�L-2 Address Bkoe T�.� License No. 8 Phone F 9 d TYPE OF.WEL'L/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ f PUMP INSTALLATION O SYSTEM REPAIR O 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 t n Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack- O Tracy Type of Casing Specifications ("1 Public (-I Other n 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 H.P. r ..,_� State Work Done a =_ Well Destruction O Well Diameter Sealing Material-& Depth d l t Depth Fi11er �ateriel b Depth ( TYPE OF SEPTIC WORK: NEW INSTALLATION I l.,,REPAIR/A.DDITLON Y( -bES.TRUCT PN.,-I_I^INo septic.s.ystem permitted if public sewer is W t available within 200 feet.) Installation will serve: Residence-eCommercial Other l Number of living units: Number of bedrooms - i Character of soil to a depth of 3 feet: A Ad T3� # - -)'- ¢ h��i r Water,,table depth _ SEPTIC TANK ❑ Type/Mfg 'Capaaty �rzl �a No. j PKG. TREATMENT PLT, ❑ d r ' f r - �,�4 � .. Method of=bisposai, j Distance to nearest: Well 46:;la�. Foundation-; Prorty'Line $ c f-� r C-;� j 11311 f LEACHING LINE ( ; g f;Fo v Total-length No. &Len Length of lines � � '- i~ I FILTER BED [-J Distance to nearest: Well "� undationl f� A ('roperty Line3730 � d j SEEPAGE PITS 11 Depth Sizer �� Number r jj SUMPS LI Distance to nearest: Well Foundation Property Line *+ rf: " DISPOSAL PONDS 0ma-- 1 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 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, y �, employ any person g such.rti.f er as to:become_subject,to..workman's,compensation.laws-of=California,-" Contractor's hiring of'sub-contracting signature j certifies the following I certify that in.the-performance-of..the work_for_which_this-permit-is-issued-, I,shall employ-per's subject to workman's compensa-tion laws of`California." The applicant must call for all squired inspections. Complete drawing on reverse side s Signed Title: ` = 3. j � - Date: FOR DEPARTMENT USE ONLY r, '`• , s qct i( Application Accepted by � .Date Area Pit or.Grout Ins c`tion b Pe Y Date Final Inspection by Date 'S �O o .fed �(�/fig 1 Additional Comments: _ ti I Applicant - Return all copies to: San Joaquin County Public Health ! Services, Environmental Health Permit/Services } F 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 y FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY GATE PERMIT'NO: i a INFO CASH . EH 13-24(REV.i i H s) f EH 21.28