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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 PERM IT EXPIRES 1 YEAR FRAM 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. ^ Job Address T» City � +D� ► Lot Size/Acreage Owner's Name C� to� Address 41!1 94E&42 61�s NSPon' 439 ! e%XL ContractorAddress License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHFR ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F) Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing F7 Domestic/Private ❑ Gravel Pack L] Tracy Type of Casing Specifications Ul Public is Other n Delta Depth of Grout Seal Type of Grout _ I I Irrigation -Approx. Depth I I Eastern Surface Seal Installed by -w Repair Work Done L] Type of Pump H.P. State Work Dona _ Well Destruction ❑ Well Diameter Sealing Materiel L Depth Depth Filler Material 5 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION.I I DESTRUCTION (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 ❑ Type/Mfg Capacity No. Compartments L PKG. TREATMENT PLT, 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE C1 No. a Length of lines Total length/sire FILTER BED 0 Distance to nearest: Well Foundation Property Line t� !h { SEEPAGE PITS 11 Depth Sire Number SUMPS E-I 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: "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 fotlowing: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workmen's compensa- tion laws of California." The applic nt r6ost call for all equired inspections. Complete drawing on reverse side. Signed X Title: Date: LS t5 FOR DEPARTMENT USE ONLY / Applicatlon Accepted by Date At L Pit or Grout Inspection by Date Final Inspection by Additional Comments: �n L✓as r�s2t.av�� - J 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 INFO FEE AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMl7'NO, f�13,24 2 r -y i1.�gIREV.1iM51 J ' D 3� aYO C5 a acr" S,�