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APPLICATION FOR PERMIT -- UBLIC HEALTH SERVICES SAN SOA@UIN COUNTY PI r i, ON ]ENVIRONMENTAL HE PHO EI(209) 8-3420 1601 E. HAZELTON AVE. , p 0 BOX 2409, -STOCgTON, CA 95201 EXP RES 1 YF FRO DATE ED (Complete isi Triplicate) for a p and 1862 and the Rules and Regulations of San Safi Joaquin County permit to construct and/or install the work herein described. This made to uin County Ordinance No. 549 Application is hereby O 4 / application is made in cpmpliancelxith San Joao C. r Joaquin County�p7ublic Health Services. Q �� Lot Size/Acreage y L�D ! �� City C� 4 - 79 1 Job Address Phone 1''r� Address rt 0 7 Owner's Name 3 o� Phone p�1 lo) �[ License No. put of Service We11 ❑ P�[/Ji OL t rAd ress DESTRUCTION, Well Contractor WELL REPLACEMENT 0 OTHER ❑ Monitoring ❑ TYPE OF WELNEW WELL LlPUMP: SYSTEM REPAIR C1 PROP, LINE PUMP INSTALLATION M SEWER LINES DISPOSAL FLD.�.-�- PITS/SUMPS �- ---- DISTANCE TO NEAREST: SEPTIC TANK ._-- OTHER WELL - fOUNDATION pGpkCULTURE WELL �--- s TYPE OF WELL PROBL_ EMAREA CONSTf�UCTION SPECIFICATIONS Dia of Well Casing INTENDED USE p Manteca Dia. of Well Excavation ❑ Open Bottom Specifications-----�- ❑ Industrial ❑ Tracy Type of Casing r d } Type of Grput I Gravel Pack Depth of Grout Seal _ O �pomesticlprivate � n Delta 1 . I_} ter I Surface Seal Installed by i"1 Public 41 i I Irrigation �� App, ox, Deptstern State Work Done `_ #t Type of Pump H.P. Repair Work Done C7 Sealing Material & Depth U' Well Destruction ❑ Weil Diameter r Filler Material A Depth Depth QSµ, available within 200 feet.}; YPE OF SEPTIC WORK: NfW INSTALLATION I I REPAIRlADDITION I I DESTRUCTION I 1 ffVo septic system permitted if public sewer is T T I � 1` Installation will serve: Aasidence'� Commercial Other�-�--�-� k �- Number of living units: N mbar of bedrooms '< r Water table depth Character of soil to a depth of 3 feet: ❑ Type/Mfg i.£^ No. Compartments "k Capacity — SEPTIC TANK 1 k f Property Line Method of Disposal Cl PKG. TREATMENT PLT. 1 Distance to nearest: Well Foundation �-- �--, 3� I Total length/size a LEACHING LINE ❑ No. &'-Length of lines. �� r i'Property Line r \! FILTER BED ❑ Distance to nearest: Well Foundation"` 1 ` SEEPAGE PITS 11 Depth ",i Size Number r r Property Line SUMPS Ll Distance to nearest: Well Foundation DISPOSAL PONDS ❑ -- ' I hereby certify that I have prepared this application and that the work will be done in accordance with Sa Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature cenifies the following: "I certify that in the performance of thwork 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 subject tow okmanisgompenssignature certifies the following: "I certify that in_the performancs of.ihe work for which this permit'SL issued, i shall employ.persons I A tion laws of California." y The applicant t cafl for all required inspepti ns: Complete draw g on reverse side. Signed itle: '�.! Date: �. F ENT tFSE ONLY j r Date �, Dw, Application Accepted by Pit or Grout' napection b pa�� Final Inspection by s�� /�. Additional Comments: LL k 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 FF£E CK MOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT NO, INFO EH 13-24IREV,ii Hsi C1 EH 11.28