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s% APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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. b � Al J - �'Z`� T-,d rte#r Cit - _ Lot Size/Acreage ' Job Address - -- y C_lr�fi Ir / c Address 1 r' r)Zn O � _ Phone��' Owner's Name � Contractor 1P,'K Pi Address °v L l� 4� �icense iso. Phone) r 133 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Monitorint, Well 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r,Q-I i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 �j� F} Industrial ❑ Open Bottom © Manteca Dia. of Weli Excavation Dia. of Well Casing r7 l_1 Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications I.l Public 1.1 Other F) Delta Depth of Grout Seal Type of Grout I i Irrigation .w. Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done Weil Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material 3 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION ( I REPAIR/ADDITION i I DESTRUCTION I I INo 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. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Totai length/size I FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS [ I Depth Sire Number SUMPS LI Distance to nearest: Well Foundation Property Line - 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: "f certify that in the performance of the work for which this permit is issued, I shall not i employ any person in such manner as to become subject to workman's compensation taws 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, l shall employ persons subject to workman's compensa- tion laws of California." The applicant m t call for all r uired inspections. Complete drawing on reverse side. Signed X Title: _ 'nda—o [F 7., ems,jlfee, Date: i F DEPARTMENT USE ONLY \ �` Application Accepted by Date C_ dam" i� Area ? Pit or Grout Inspection by p f _ / Date / Final Inspection by— __-- _ _ - Date Additional Comments: ___L( �1!®"ut- G/lt �1 ie,, 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 IF AMOUNT DUE AMOUNT REMITTEDC 9H RECEIVED BY DATE PERMIT'NO, EK+ EH 7/.�IREV.t i K 51 go- lvU ..