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� . . APPL I CATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON.- CA 95201 4 EBMIT EXPIRES 3 YEAR FROM DAIT IS$UED (Complete in Triplicate) Application is hereby made to S quin ZC'unty for a permit to construct and/or install the work herein described. This application is rade in compliance with San Joaquin County Ordinance No. 549 and2 and the Rules and Regulations of San Joaquin County Public Health Services. f j�� D d 5U0 04PAI Q S9—0'-70-93q *&T Job Address . 4066119'7Jb fAY22,!" �c O-F ..STM_ City /Acreage Owner's Name 4eV>r, Address 6!92y�6 Phone Contracto Address;My57 A MY/274if ;EZ License No-67ZZ6$ Phone q �^ .TYPE OF WELLIPUMP: NEW WELL CI WELL REPLACEMENT ❑ ^.,_ DESTRUCTION Cl Out--of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER`1W.,7��+�7�1N4SS DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES Y DISPOSAL FLD, ?09P-61k ry D/ FOUNDATION AGRICULTURE WELL OTHER WELL -fisu6AP�. _ t r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation << y •1-1 Domestic/Private 0 Gravel Pack El Tracy -Type of Casingations �-SIF 41C_ + i'1 Public EI Other F-I Delta Depth of Grout Seal Type-at--Cuout. B/ -0c14, - .... rf a I. I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by. Repair Work Done 0 Type of Pump H.P. State Work Done _ t`'n mis he, Well Destruction ❑ Well Diameter Sealing Material. & Depth Depth Filler Material b Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I i INo septic system permitted if public sewer Is 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.❑ 1 Method of Disposal Distance to nearest: Well foundation Property Line v` i LEACHING LINE ❑ No. A Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation . .._ Property Line DISPOSAL PONDS 0 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, I shall employ persons subject to workman's compensa- tion laws of California." i The applicant must call for all re d inspections. Complete drawing on reverse side. I Signed Title: _&&fdal Date: --_ •� °� FOR DEPARTMENT USE ONLY g Application Accepted by Date < Area I Pit or Grout Inspection by 1 Date Final Inspection by Date Z!) Additional Comments: Applicant - Return a.11 copies to: San J1.44in County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 INFOAMOUNT DUE AMOUNT REMITTED CAS RECEIVED BY DATE PERMIT NO. FEE -6 I « EH 1324(REV.11"51 q EH T4.26 I �t C� cif lei c� o X09