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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 BOR 2009, STOCKTON, CA 95201 RES 1 YEAR FROM DA h' 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. p Job Address . _ -tom�� / City #+'&4TCG('Lot Size/Acreage ri�7 & CF�, Owner's Name m)i�f e L.,u Je?-6,._z Address � y f.. O e VA-fl/J- r Phone gZ a Contractor s P L Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Q 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 n industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing F1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'l Public CZ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth l I Eastern Surface Seat Installed by Repair Work Done 0 Type of Pump H.P. State Work bone _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION * DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feat.I Installation wilt serve: Residence P--**' Commercial_ Other Number of living units: __L_ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines -7Total length/size FILTER BED OP-bistgrtce to nearest: Well >{_0� Foundation .__�e� Property Line r, O L ✓I 62• 1 C-)e- - SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Welt 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 laws of California," Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for this permit is issued, I shall employ parsons subject to workman's compensa- tion laws of California." The applicant must call II requir inspections. Comglete n s' ,yJ l Signed X Title: L./ -e� Date: DEPA MENT USE ONLY Application Accepted by ZF Date A ea C" Pit or Grout Inspection by Date Final Inspection by Dat Additional Comments: Applicant - Return all copies to: Sen 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 INFO RECEIVED BY PATE PERMI1'N0. . EH 1324 IREV,w p 5! EH C3 t4.2e w G� l