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APPLICATION FOR PERMIT I 3� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERIIEIT EXPIRES 1 YEAR FROM DATE IS$UED (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 1662 and the Rules and Regulations of San Joaquin County Public Health Services. AVEJob Address 2-32 ,30 66-1-6 VCity I Lot Size/Acreage Owner's Name 600 Address 1065 COAtS7777w% or )/ cam/ y - --' Phone 936 — r]00 �y Contractor F Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 0 DISTANCE TO NEAREST: SEPTIC TANK 3i9 SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C] Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing to Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public i.1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _.ApproK. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done_ a Well Destruction Well Diameter Sealing Material & Depth Depth __ __- Filler Material & Depth _ o[4 gE1U _b Al l 725 _ _0,4021rlfC,F_ f A} TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION [ I lNo septic system permitted it public sewer is v available within 200 feet,l 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. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 11 No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS L1 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, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all re redi ,c�tionds.,Complete drawing on reverse side. Signed X fl-` Title: ►^-- Date: ✓� O QJ FOR DEPARTMENT USE ONLY r �. Application Accepted by Date A Area �1 ' Pit or Grout Inspection by Date Final Inspection by 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 INFO FEE AMOUNT DUE AMOUNT REMITTEDCK N RECEIVED BY DATE PERMIT'NO. Ih « EH 13-241fIEV.i/a5i �S fns �' CJ �D ��j� �� 1q0_ EH 44-2a i