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APPL J,CAT I ON FOR PERM I T SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 ' P O BOX 2009, STOCKTON, CA 95201 jPRUIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) r 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 yHeaaltth Services. IF Job Address �� /l / � CityLot Size/Acreage t - Owner's Name C Address Phone f Contractor��/`'tel-tAr_Address �1� 15�� /1� .,, License":Q_e �_Phone I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ f PUMP INSTALLATION ❑ SYSTEM REPAIR.❑ ? OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEINER LINES DISPOSAL FLD. PROP. LINE +` FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I: ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation —Dia:;of Well Casing Ll Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'I Public I:1 Other n Delta Depth of Grout Seal Type of Grout �\ I I Irrigation _�.Apprax. Depth 4 I Eastern ,� Surface Seal Installed by \ y Repair Work Done U Type ofd Pump H.P. State Work Done y Well Destruction ❑ Well Diameter Sealing Material & Depth ��. c �r Depth tFiller Material & Depth TYPE OF SEPTIC WORK: NEW INSTAL LATIONX.AEPAIR/ADDITION [ I DESTRUCTION N Mo septic system permitted if public sewer is ' available within 200 feet.l + Installation will serve: Residence ommercial'_-'7— (Other Number of living units:, Number of bedrooms- Character of soil to a depth of 3 fear. Water table depth l SEPTIC TANK.- ❑ Type/Mfg = +;Ld € Cap ity��------- No. Compartments PKG.�TREATMENT-PLT, ❑ "' ru>'rra _ Method of Disposal,. I Distance to nsaie'st:- Well- F/oundation . �,,,.•. Property Line LEACHING LINE fy�No. & Length of lines y Total length/size FILTER BED Cl Distance to nearest. Well " Foundation ,� c 4 Property Line SEEPAGE PITS [' Depth s�``�' '-Size Number SUMPS Ll Distance to nearest:f Well Foundation}�� Property Line # , DISPOSAL PONDS ❑ r 'f 1 hereby certify that I have prepared this application and thatiha work will be done in accordance with San Joaquin county ordinances,'st`ate laws, and M rules and regulations of the San Joaquin County """'� Home owner or licensed agent's signature certifies the following: "I certtW9tthat 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 of sub-contracting signature certifies the following: "I certify that in the pertormarice of-the work for which this permit is issued, I shell employ parsons subject to workman's compensa- tion laws cf-California." f The applicant must call for II re `ired ins ctions,�Complete drawing on reverse side'.\ Signed X_ Titley -��y.+r _ Date: f E 1 i t• FOR DEPARTMENT 115E-ONLY- - I Application Accepted by Date 7 Area } Pit or Grout Inspection by ' Date Final Inspection by Date I Additional Comments: YF Applicant _ Return all copies to: San Joaquin County Public Health i Services, Eavironmental,Realth Ptsrtatt/Services ? ' 1601 E. Razelton Ave., P 0 Box 2609, Stockton, CA ;95201 TE ICK I NFO AMOUNT DUE AMOUNT REMITTED CASH RE:CEIVEDAY ^ _DATE PERMIT'N0. f' EHA3:24JAE;,-', tr—a') ""`:.. _ .w. -.�i••,-,:cam. - -�,L.•.r---.'_.. -.�.�.` �'b -.,,•. +-• • EH 11.2E