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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES [ ENVIRONMENTAL,HEALTH DIVISION F� 1601 E. HAZELTON AVE. , PHONE (209)468-3420 J 1 P 0 BOX 2009, STOCKTON, CA 95201 �1 pERYTT EMIRES 1 YEAR FROM DA UB_D (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. 077 e .e,L�i�Q fZ� City '�J�� Lot Size/Acreage ys-Oo Job Address _ /�f.$b Q A Address S Phone 7f- Owner 9 Owner's Name T ^� Contractor A7Z - b Address Al DEL,QE 6Li+cense No. Phone r'3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION Ll Out of Service Well C PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE -n FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications !"1 Public Cl Other y. n Delta '� � Depth of Grout Seal Type of Grout. `. I I Irrigation —.Approx. Dep6" l I Eastern " Surface Seal Installed by y Repair Work Done. 0 Type of Pump E' H.P. ' State Work Done_ Sealing Material & Depth Weil Destruction ❑ Well Diameter ,, I -' Depth Fillerj.Material & Depth ' TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION'N DESTRUCTION l-I (No septic system permitted if,public sewer is e available within 200 feet.) Installation will serve: -Residence /Commercial____ Other' " Number of living units: L Number of bedrooms Character of soil to a depth of 3 feet: SAT- C .9 y - — Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity lid O -No, Compartments L PKG. TREATMENT PLT. ❑ Method of`Disposal Distance to nearest: Welles•-,- foundation Property Line LEACHING LINE L No. & Length of lines Z494P Total length/size FILTER BED ❑ Distance to nearest: Well l 969 ' Foundation 2g2 Property Line 7-f 4 • SEEPAGE PITS I I Depth Size Number � SUMPS Cl 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 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 California," The applicant must call for all required inspection$..Complete drawing on'reverse-side. Signed X ME Title: Date: Z r 1 4 FOR DEPARTMENT USE ONLY Application Accepted by Data '77/2-Q Area / Pit of Grout Inspection by Date Final Inspect' by:l= Date 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 F FEE AMOUNT DUE AMOUNT REMITTED SH RECEi D BY DATE PERMIT'NO. I INFO + EH 17-24 IpEV.riqA EH 91-28 f