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- APPLICATION FOR PERMIT i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. .HAZELTON AVE. , PHONE (209)468-3420 !� P 0 BOR 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED " i (Complete in Triplicate) Application is hereby made.to San Joaquin County for a permit to construct and/or install the work herein described. This applicationis 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 ,19,301 r✓�City Lot Size/Acreage 11 /`Owner's Name l�.4A�ht``u'� � t " v�� •)�� Address �� 1c��.l�w�..�R..t Phone Kf \ Contractor c4sltl Address " f' Licens0o.11. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ = ,:.,WELL-REPLACEMENT❑„._.•„„,,,,_OESTRUCTION ❑'Out7of'Service Well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ,olMonitoring Wel O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1111 FOUNDATION AGRICULTURE WELL.•- �- --.OTHER.WELL.,PITS/SUMPS.- 411- . INTENDED USE TYPE OF WELL PROBLEM AREA'_CONSTRUCTION SPECIFICATIONS I f n Industrial 1 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C:1 Domestic/Private ❑ Gravel Pack � N ❑Tr cy Type of Casing 'i—Specifications} j i'l Public li Cl Other ;0 F1 Delta Depth of Grout Seal ..Type of Grout I I Irrigation i� _.ApproK. DepthF 1 I Easiern Surface Seal Installed by �' V ^/ `- Repair Work Done U Typ of Pump ?” H.P. State Work•Done Well Destruction ❑ Well Diameter Sealing Material & Depth 1 f Depth Filler Material & Depth } r TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I.1'"(No septic system permitted it,public sewer is available within 200 feet.) Installation wi� ll serve: Residence_ Commercial_ Other Number of living units: f Number of bedrooms E j Character of soil to a depth of 3 feet: Water table depth t _ T_ ,�. SEPTIC TANK _/ O Type/Mfg Capacity No. Compartments PKG. TREATMENT;PLT. ❑ f Method of Disposal - II Distance to nearest: , Well t" Foundation Property Line -� I � - a LEACHING LINE ❑Y.,No.,& Length of,.lines Total length/size I '` FILTER BED �# Cl Distance to nearest: Well Foundation Property Line °: $ I SEEPAGE PITS I I Depth Size _ Number SUMPS j E� 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;`aria.•_ rules and regulations of the San Joaquin County I 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, 1 shall employ persons subject to workman's compens tion laws of California." The applica t must call for all squired in tions. Complete drawing on reverse side. I I Signed ixl \S1Title: Date: EPARTMENT USE ONLY Application Accepted by Date Area ` <k"7-741- PWvt-Gretrt Inspection by Date 27 Final Inspection by ! Date III � r Additional Comments: X°l+ µW1—� P03 /d `ZM� r Applicant -i�IReturn all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services �F 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201FEE i ^ INFO AMOUNT DUE AMOUNT REMITTED CK 11 CASH RECEIVED BY DATE PERMIT'NO. . EH 13-24(REV.rins) EH 14.28 Q, �/Q• i