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APPLICATION FOR PERMIT 71 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES / ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIX %P RES I YEAR FRQM DATE 15SUED (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 Count ae NA. 549and 1862 and the Rules and Regulations of San Joaquin County Public Health Services, ' 64�42 �� 1 Job Address A City _Lot Size/Acreage � ✓- - Owner's Name d r/ 1 -- - __ Address Phone Contractor Address -57.2License No:l ' T47 5!��Phone TYPE OF,WELL/PUMP:.- r } . _ NEW WELL ❑ Y�Y WELL R_LACEMENT_❑_ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR L) OTHER -❑ Monitoring Well 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 . n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation s, Dia. of Well Casing [I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ �° � Specifications 3 I') Public 1-1 Other s. fl Delta Depth of Grout Seal Type of Grout I I Irrigation �, "Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done . 0, Type of Pump -- H.P. State Work Done �, Sealing Material & Depth Well Destruction ❑ Well Diameter t Depth "'7 " ""Filler Material & Depth r TYPE OFSEPTIC WORK:"NEW"INSTALLATION I I REPAIR IADDITION DESTRUCTION FI (No septic system permitted if public sewer is CNI -� 'O'k „, � F. r available within 200 feet.) Installation will serve:.*Residence_ Commercial Other:. - � ,t. z _ r xx Numbe"r of-living Unita: Number of bedrooms�. Characttfrof soil to a depth of 3 feet: ��- g Water table depth SEPTIC TANK: 0 Type/Mfg "r Capacity 1 a we;, No. Compartments PKG. TREATMENT PLT.❑ m Method of Disposal Property Line y Distance to nearest: 0 Well Foun anon Pr R LEACHING LINE ❑ No'S Length-of�lines _ r--- - _ Total length/size FILTER BED 1=1 Distance to nearest: Well Foundation Property Line i SEEPAGE PITS I I ZVPVh d22 42 @Wo p_y-�X 014umber SUMPS L-I Distance to nearest: Well-- foundation `Property Line DISPOSAL PONDS - ❑, X. I hereby certify thit_Irhave'prepared this application end,that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and reputations 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." The applicant must I��r�a�egairAd inspe tions. Complete drawing on reverse side. � Signed X _ /fid) ��jJ Title: 6- _ Date:bF 0JPARTMIENT USE ONLY ,� t Appli 'on Accepted by Date1 1�] Area �Pii rout ns ction by Date Final inspection b Date Additional Comments: 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 AFEEMOUNT DUE /¢yA�MOUiN(TfiREMITTED CA5H�✓ RECEIVED BY DATE/ PERMCK I lT ND. . EH17"24 IREV.i i n Sl EN 14.26