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APPLICATION FOR PERMIT 1 r _ SAN JOAQUIN COUNTY P � UBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 �4 � P O BOX 2009- S TOCSTON, CA 95201 EXPIRES I YEAR FRO,}d DATE Ep (COMP lete in Triplicate) Application is hereby made to San Joaquin County for a appllcatloa is made in compliance with San Joaquin County Orttinancepermit to nNaru51+9ct aando18628aad the work herein described. This Joaquin County Public Health Services. /` . Rules and Regulations of San Job Address q„ �tZ 7�/ � �� City Lot Size/Acreage Owner's Name i[01 �� } Address Contractor t'l/ RaTr �lq Phone ?,?r TYPE OF WELL/PUMP: Addret 77, I [, NEW WELL ❑ License No. Phone 7.3 T"972-P PUMP INSTALLATION WELL REPLACEMENT 0 DESTRUCTION Out of Service Well ❑ DISTANCE TO NEAREST: SEPTIC TANK Z� SYSTEM REPAIR ❑ _ OTHER ❑ Monitoring Well 1 .-. ,SEWER LINES U FOUNDATION `IN ---- DISPOSAL FLD.11.0 PROP LINE ZO --� AGRICULTURE WELL ��' OTHER WELL t� - • INTENDED USE TYPE OF WELL PAOBLEM AREA CONSTRUCTION SPECIFICATIONS P1rS/SUMPS i n Industrial p Open Bottom ❑ Manteca Dia, of Well Excavation ® J Domestic/Private ravel pack Dia. of Well Casing -�._ [ F)) Public, ❑ Trac Tracy ',^-,.,.,..-�..TYpe..of Casing . IA�G U] Other Ll Delta Depth of Grout Seal Specifications �` 4 I Ipair Work LTA?.Approx. Depth ! I Eastern Type of Grout Repair Work Done L7 Type of pumpSurface Seal Installed by Well Destruction . Well DiameteSealing ` State Work Done Q rJ r n8 texial & Depth Depth Jty Filler Material & Depth j TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I flEPgIR/ADDITION I I DESTRUCTION I i (No septic system permitted if public sewer is R Installation will serve: Commercial-�° available within 200 feet.) Other - -�*+.,,.. Y Number of living-units: f Number of bedrooms Character of$oli to a depth of 3 feet: it -T # SEPTIC TANK "'❑ Type/Mfg '' 1' i � I .�• Water table depth PKG. TREATMENT PLT, C1 �� Capacity No. Com artments Et� ._�..;.. �i P 7— ��• Method of Disposal Distance to nearest: €,Well ' Foundation — Property Line ,} F Cdr t, i � , LEACHING LINE _` ' # L1 No. & Length of lines FILTER BED p Distance to nearest; WellTotal length/size Foundation =!�. Property Line SEEPAGE PITS 11 Depth Size SUMPS Number Ll Distance to nearest: Well Foundation DISPOSAL PONDS Q Property Line 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: � � employ an g: "I certify that in the performance of the work for which this permit is issued, I shall not j P Y y person in such manner as to become subject to workmen`s compensation laws of Califoinia," Contractor's hiring or sub-contracting signature tionIles the following; "I certify that in the performance of the work for which this permit is issued,.Nihall employ persons subject to workman's compensa- tion laws pt California." The applicant mu calf for all required inspections. Complete drawing on reverse side. t r Signed Title: I%- - Date: FIQR DEPARTMENT USE ONLY Application Accepted by Date—S�`9 1— Area Pit or 0)nspection by Date Fin al l f A ns action bD Additional Comments; 6 y ate L Appl1cant - Return all copies to: San Joaquin County Public Health 1r, AR IL Services, Environmental Health Permit/Services 1601 E.' Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTEb CK Nf _ A CASH RECEIVED By DATE 0 EH 13-24 PFRMIT'NO. EH t{.Ig I 9a- s � )fin