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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 O BOIL 2009, STOCKTON, CA 95201 PMWIT EXPIRES 1 YEAR FROM DATE ISSUED (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. � City Lot Si�ze/Acreage Job Address 27 Owner's Name -�Ss AddressA a _ td� / Phone .-2 Contractor T Address License No. �'*7/ _Phoneme 4 TYPE OF WELL/PUMP: NEW WELL ❑ WELL R PLACEMENT ❑ DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ci Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing C1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'l Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout II Irrioation _Approx. Depth I I Eastern Surface Seal Installed by ( n Repair Work Done LJ 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 W--'-REPAIR/ADDITION I I DESTRUCTION I I iNo septic system permitted if public Sewer is available within 200 feet.l installation will serve: Residence E/ Commercial Other Number of living units: ---{--- Number of be roams Character of soil to a depth of 3 feet: Water table depth V u SEPTIC TANK e Type/Mfg Capacity. No. Compartments PKG. TREATMENT PLT. ❑ 1 Method of Disposal Distance to nearest: Well + Foundation /® _ Property line Z'_,_ LEACHING LINE CW No. & Length of lines C3 , f r Total length/size f FILTER BED ❑ Distance to nearest: Well +� Foundation Pr Property Line 1 SEEPAGE PITS A-�-Depth size _ Number �?�! SUMPS LI Distance to nearest: Well L j�t Foundation Property Line DISPOSAL PONDS a 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 workmen'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 persona subject to workman's compensa- tion laws of California." The applicant u t call for all reqldifed,'nspections. Complete drawing on reverse side. Signed X r Title: -_c�ev�a tl, s Date: al _ FOR DEPARTMENT USE ONLY 1 -1 Application Accepted by rn"��-o*-� ^� — Date 2 �2 1_� Arse Pit oGrout Inspection by Dater t i Final Inspection by �3 DataZ� Additional Commlttits: 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 CK RECEIVED BY DATE PERMITNO. INFO r/�� (�[ CASH + EH 13-24 IREV.)"W vim--' �-^-' Q Q( q l ` o EN.445 14114