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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 RRM ff EXPIRES 1 YEAR FROM DATE I.9jSUED (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. AC fQf 17�SS 5 C,Ytc� 3 JobAddressilAR � -190-�� __ City Lot Size/Acreage Owner's Name A A'" Address ARA rn t - _ Phone Contractor!t,�,r�'T� C�1�A� Address / O /-�0�[ License No. 77.3 k-r Ph,,e20_ TYPE OF WELL/PUMP: NEW WELL 91 WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of service Weil ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well G7 DISTANCE TO NEAREST: SEPTIC TANK i/"L 1, `4 SEWER LINES DISPOSAL FLDtS 4: PROP. LINE 162 FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation jer Dia. of Well Casing }q� Domestic/Private X Gravel Pack n Tracy Type of Casing e-1--c Specifications r �� - V I'1 Public 1-I Other n Delta Depth of Grout Seal dD Type of Grout_C� I I trn{tation ZS a ..ApproK. Depth l I Eastern Surface Seal Installed by "1 Repair Work pone ❑ Type of Pump r'leZT H.P, -1 State Work Done f� 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 I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ 'CommercialtL Other Number of living units: Number of bedrooms_ Character of soil to a depth of 3 feet: Y Water tabs depth SEPTIC TANK ❑ Type/Mfg _ Capacity No. Compartments PKG. TREATMENT PLT, 0 Method of Disposal Distance to nearest: Well Foundation Property Line X, w LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS 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, 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 taws 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 c II for ll required inspections. Complete drawing on reverse side- Signed X Title: 0-tA.— Date:4L ' Lv II FOR DEPARTMENT USE ONLY Z Application Accepted by Date Area Pit b►/ roJ� Inspection by Date Y Final Inspection Dated i V 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 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERM17'NO. INFO q + EH 13.24(REV.1/ 5) Q 50 1 1 EH 14.26 �� I Ll "Z�