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APPLICATION FOR PERMIT j r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PEMIT EXPIRES 1 YEAR FROM DATE JSaPED f (Complete in Triplicate) i 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. rN p i7-f3 1 II' JeZ r ,d y�Q �^ Lot Size/Acre Job Address -7- City�2,,ZZCn�e C�lr t Ir �1 l 1 ) .b Pho � -f J' Owner's Name Address e� 4 c_ S Z, Nf �1� S�-s`�' b �S� Pr y 9 'Q�S ' Contractor K Address o� License No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Monitoring Well 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. P. LINE > 2JQ a FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS k/ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F! Industrial CJ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing CI Domestic/Private 0 Gravel Pack LJ Tracy Type of Casing Specifications �7 I'I Public is Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION f I (No septic system permitted if public sewer is available within 200 feet.) 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 D Typa/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line I ' LEACHING LINE ❑ No. & Length of lines Total length/size f FILTER BED 0 Distance to nearest: Well Foundation Property Line t I k SEEPAGE PITS IJ Depth Size Number f SUMPS LI Distance to nearest: Well Foundation Property Line C 4 DISPOSAL PONDS ❑ 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 I 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." The applicant m t call for allr wired inspections. Complete drawing on reverse side. / e } Signed X Title: Gh✓*�oKr�,eF r,�� Date: 6 9 I F DEPARTMENT USE ONLY Application Accepted by Date C- l� Area� a Pit or Grout Inspection by p /� ryryJf Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services ' 1601 E. Hazelton Ave., F 0 Box 2009, Stockton, CA 95201 IP AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT'NO. -3�fREV..in 51 / FH i�x EH Iry 90- �U - - f