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APPLICATION FOR PERMIT ` SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES NOotv - ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 N,o P O BOX 2009, STOCKTON, CA 95201 P__XRMIT EXPIRES 1 YEAR FR(Z!d__DATE ISSUED tS (Complete in Triplicate) i P fcc 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. YfJL�n�. City �� Got Size/Acreage Job Address l � r JG d Owner's Name 63Z22, Alh7ar4 Address c�� y _r]l _ - _ _ Phone p d S Aonttactor StZE Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ r WELL REPLACEMENT ❑ DESTRUCTION 51 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C3 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AG RE WELL �G�ER WELL PITS/SUMPS INTENDED USE ,TYPE OF WELL PROBLEM AREA CONST ON SPECIFICATIONS r=1 industrial ❑ Open Bottom 0-Manteca Di Well Exca n Dia. of Well Casing Ci Domestic/Private ❑ Gravel Pack L] Tracy ype of Casing Specifications Q� Il Public 1-1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth I I Eastern- " Surface Seat Installed by &I Repair Work Done L7 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Depth Depth Filler Material b Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION lNo septic system permitted if public sewer is available within 200 feet.) [� Installation will serve: Residence_ Commercial — Other (\` Number of living units: Number of bedrooms •3 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. © Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.Cl Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE D No. & Length of lines Total length/size FILTER BED CI Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll 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, f 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 call for att required inspections. Complete drawing on reev+errse side. igned X 4 ar _ � Title: E/Cwt..,_..�L ,._,.,.. Date: 7-1. ARTMENT USE ONLY Application Accepted by Date ___J=1 , Area Pit or Grout Inspection by Date Final Inspection by 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 EE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATES PERMIT'NO. EH 14-241REV.rill L t�� -7-1 lc- 1 / `I� i7 EH 9i�2E lJ V f 5