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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201. pEU IT EXPIRES L YEAR FRQM DATEED (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. C `eS City �G Lot Size/Acreage Job Address q �,.-� t� Owner's Name Address ® Phone t �- (fes �C�� ense N12 o, �� Phone 20 J 7 Contractor *JJ _- tf Address TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEN!ENT CJ DESTRUCTIONS❑ Out of Service Well ❑ { 4 OTHER ❑ M°nitoring Well C1 PUMP INSTALLATION E) ____� SYSTEM REPAIR C] li DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n pia. of Well Casing Industrial ❑ Open Bottom ❑ Manteca t f Dia. of Well Excavation a of Il Domestic lPrivate Cl-Gravel,Pack.....-•-.-+-❑•Tracy�x r r;.T;Yp � Casing_:.- r Specifications , I"I Public 1-1 Other f 1 Delta , 'Depth of Grout Seal F _ Type of Grout Approx. Depth I I Eastern � Surface.Seal Installed by I I Irri0ation G + Repair Work Done 0 Type of Pump 4 H.P. d t i State Work Done i Sealing Material & Depth 613 i Well Destruction ❑ Welt Diameter . , 1 [?epth f Filler Maeria ; l & Depth N TYPE OF SEPTIC WORK: NEW-INSTALLATION-IEPAiR/ADDITION l?L.-DESTRUCTION I 1 INo septic system permitted if public sewer is t t available within 200 feet.) Installation will serve: Residence.1C^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. GL/ ... opacity- 1!J__a 6 -- No'Compartments C!_1 C,1A Ir PKG. TREATMENT PLT:, < Method of Disposal G Distance`to'nearest: Well Foundation �9 D_— Property Line I�I + i '. LEACHING LINE ZP-No. & Length of.lines 2 U d € .� Total lengthlsire Z IF FILTER BED ❑ Distance-to nearest: Well VINV750oundifi6n, Property Line Q p ^- SEEPAGE.PITS„„ l I Depth - Size i Number SUMPS �Ll Distance to nearest=" Well-- Foundation Property Line f DISPOSAL PONDS ❑ A I hereby certify that I have prepared-this,applicatiomand-that-the-wo=k will-5e-done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County s Home owner or licensed agent's signature certifies the following: "I certify that in'the performance of the work for which'this permit 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." z { I+ Theapplicant mu t call for all required inspections. Complete drawing on reverse side. ,f } _ Date: 3 -36 I Signed X Ei FOR DEPARTMENT USE ONLY I' Application Accepted by Date 11,310 Area .� Pit or Gout Inspection by Date Final Inspection by Date " 3o Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health la Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE. PERMIT N0. Ik INFO + EH i3:244REV.irae) -70 k/10 EH 14.26