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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION f : t � 1601 E. HAZELTON AVE. , PHONE (209)468-3420 U P O BOX 2009, STOCKTON, CA 95201 PERMIT—MIRES -1 YEAR FROM D j1.ED (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. Job Address /71 OA-j4 r City 'Lot Size/Acreage Owner's Name &y& Address 407I / Phone r ��p Contractor ` Address �F License No, Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ 1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well C] DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION_--------_AGRICULTURE WELL OTHER WELL PITS/SUMPS _ T INTENDED USE TYPE OF WELL PROBLEM AREA CO N SPECIFICATIONS i n Industrial ❑ Open Bottom�_-0-Manteca __ .Dia-0f_Well-Excavat,o - Dia. of Well Casing 1 fa Domestic/Private ❑ Gravel Pack iI C1 Tracy Type of Casing t Specifications f Ll ' I'! Public Ci Other } n pelta Depth of Grout Seal t`of�Grout '"NI I Irrigation Approx, Depth I I Eastern Surface Seal Installed by. Repair Work Done ❑ Type of Pump t fi.,P: State Work Done Well Destruction ❑ Well Diameter . , _ Sealing Material & Depth i Depth 1 `1, vj `'Filler Material & Depth 14 TYPE OF SEPTIC WORK: NEW INSTALLATION-l-l-»•REPAIR,LADDITION I DESTRUCTIOf" -,.iNo septic system permitted if public sewer is u available within 200 feet.) Installation will serve: Residence_ Commercial'._`, Number of living units: Number,of bedrooms Character of soil to a depth of 3 feet: i * 1 �`� NWateritable depth f SEPTIC TANK Type/Mfg Capacity f' No. Compartments PKG. TREATMENT-PLT. 0 j f ;Method of Disposal "-'•—Distance to nearest: Well i rFoundation Property.Line, �,'• ' i T ? ' LEACHING�LINET No. & Lengtht of lines 1 JCI i✓S' J Total lengthTssize� I� FILTER BED\\ Distance to nearest: ,Well ( Foundation _ Propeity'Line t SEEPAGE PITS A Depth Site; ft 4�!_. .__._ Number __- Je SUMPS CI Distance to nearest: Well +''Foundition T l Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that tha work will be.dor�6,in-accordance-with Sin Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County l t {i :; µ=- Home owner or licensed agent's signature certifies the following: "I nertify that in the-performance�o,f 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 iarw-3•of Cafifdrhia." Contractor's hiring or subcontracting signature certifies the following: "I certify that in the performance of the work for which this p6 mlt is'l`ssued, I shall employ persons subject to workman's compansa- tion..laws.of_C8lifarnia-->'- �-�--�----"•.,—,:.�.x... .� The applicant m t call for all r ' ttttuir inspe ons. Complete drawing on rev" se side, r. ,,,.._.,.,._Signed-X - �_ __. _ _ - -- �'Title:'�`" Date: FO EPARTMENT USE ONLY i- t� w I nation Accepted by fin z. . _ Date Z t Area E Pit or Grout Inspection by Date Final Inspection by ` Dste I 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 FEE_I 11 INFO AMOUNT D,UE+� AMOUNT REMITTED CASH nRECEIVED BY DATE J�PERMIT'NO.'^7 f . EM 13-24(REV. /n SS 14 1,- ,Ctl (l 1 EH 34.26 L 11-mgl l