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ter/ ^rte 1 N i ^ / , APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)458-3420 ` P O BOR 2009, STOCKTON, CA 95201 PFJtMIT EXPIRES 1 YEAR FROM DATE IPSUED (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 ® Cit Lot Size/Acreage IdZeler /'' Owner's Name cmg 1n✓ / l'CX Gl��_ Address �/�1`7-P Phone p �-� , --- ContracllWf d"dress r � .' - —License No "Phone' .� TYPE OF WELL/PUMP: NEW WELL WELL REPLACEM T ❑ DESTRUCTION ❑ out of Service Well ❑ t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD,JiM PROP. LINE _,LV i FOUNDATIONAGRICULTURE WELL OTHER WELL., - PITS/SUMPS �- f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C_7 Industrial Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing =� E7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing J7 Specifications I'I Public I-1 Other n Delta Depth of Grout Seal /4" Type of Grout y�Irrigation _..Approx. Depth f I Eastern Surface Seal Installed by 42-P - lRepair Work Dane 0 =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 REPAIR/ADDITION I I DESTRUCTION # 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 i i SEPTIC TANK ❑ Type/Mfg Capacity------ No. Compartments PKG. TREATMENT PLT. ❑ ' Method of Disposal f Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No.& Length of lines Total length/size �. FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth f Size _ Number SUMPS LI Distance to nearest: - ,,,Well Foundation— Property Line DISPOSAL PONDS El 4A° 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 signatures - ce6fies the following: "I Certify that in the performance of the work for which.this.permit is•i8sued;'I'shell employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspection Complete drawing on reverse side. Signed Title: Date: FOR DEPARTMENT USE ONLY I Application Accepted by Dater d Area Pit or Inspection by Date Final Inspection by L.. Date Additional Comments: _ �Y W i 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CK 0 CASH /RECEIVED-.BY___ _ - �D/ATE. �'- `PERMIT�w. . EH V 13-24IR£V.�inSf x`60 ,.� S -S-8--50 ! EH 14-28 v 7