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y APPLICATION FOR PERMIT ti t SAN JOAQUIN COUNTY PUBLIC .HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1501 E. HAZELTON AVE. , PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 95201 PFRMIT EXPIRES 1 YEAR FROM DATE igaUJED (Complete^in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. -This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. t Job Address � ` -72-8Z S-919,64,6-city Lot Size/Acreage p-3A u_; 74AJOwner ]f 's Name . �fA + �'�� Address ilJi[� Phone Contractor1L Address _ l� ` `�(�S�xr$Yll �License N.- Phonek TYPE OF WELL/PUMP: NEW WELL —❑ WELL REPLACEMENT i1 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION fk� SYSTEM REPAIR L� OTHER ❑ Monitoring Well C� -DISTANCE TO NEAREST: SEPTIC,TANK SEWER LINES ., OISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _? INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. 6f Well Casing --I-- 1] 1] Domestic/Private._ ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'I Pliblic El Other n Delta Depth of Grout Seal Type of Grout I Irrigation Approx. Depth l I,Els tern Surface Seal Installed by t� P � pc� IV Repair Work Done Type of Pum � H.P. �l� State Work Done pp Welt Destruction ❑ Well Diameter Sealing Material & Depth {+,� Depth Filler Material & Depth 1� TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIRlADDITION I I DESTRUCTION] 1,tNo septic system permitted if public sewer is available within 200 feat.I ; Installation wilt serve: - Residence— Commercial— Other Number of living units: Number of bedrooms ��. Character of soil to a depth of 3 feet: Water table depth w SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments I PKG. TREATMENT PLT.❑ Method_o Disposal Distance to nearest: Well Foundation Property Line 4V W f V1 fi LEACHING LINE CI No. & Length of lines Total length/siz MVWIIIIIIIIIIIIIIIIIl� FILTER BEd ❑ .,Distance to nearest: Well Foundation Property Line MU 181992 _ SEEPAGE PITS 11 Depth Size Number SUMPS l_I Distance to nearest: Well Foundation Ptoperty —T� EARTH I DISPOSAL PONDS C1 ��HMI I RV'ICE.?-.. I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state Paws, and rules and regulations of the San Joaquin County _ r Home owner or lice sed 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 Per, n such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the fol ng: "I 'fy that in th erformance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of C rnia," _ I The ap 'ca ust c fo r uire spections. Complete drawing on ve Signed X Title: Date: —1-4 A .FOR DEPARTMENT USE NLY Application Accepted by x Date �' Area Z Pit or Grout Inspection by Date Final Inspection by Date �2- Additional Comments: i 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 INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT-NO. . EH13-24 IREV.I/x si ® # r/ r r� p A ry EH 9{•2e.._ /� oc7 @b �3 �-! C� • �!J ,f i. A