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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISaL (Complete in Triplicate) r *Application is hereby made.to San Joaquin County for a permit to construct and/or install the vork herein described. This application 1s made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address ._JeV —GA J- City LI1�,7J Lot Size/Acreage Owner's Name&U XL!tJ-e_ -. 43220:T4 e5 Address 16VOffAl Phone pckk Lle- Contfactor A Address C7! F. Rb)_�pC �V/f.� License Pio. 3L'1 Cao �)'2- Phone TYPE OF WELL/ UMP: NEW WELL D WELL REPLACEMENT ❑ DESTRUCTION ❑ out of Service Well Ll 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'',."' F1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C.1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f'l Public 1-1 Other 1-1 Delta Depth of Grout Seat Type of Grout I I irrigation — Approx. Depth l 1 Eastern Surface Seal installed by Repair Work Done 0 Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION- REPAIR/ADDITION Irl-- ESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: 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 ly JP LEACHING LINE No. & Len Length of lines - /d ` a g Total iength/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth _ �� Sire Number SUMPS L3 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby cartify 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." 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 call for all regZ,ed insPections. Complete drawing on reverse side. Signed X 1I^s`Y+'t �_(�/,r Title: Date: � � 0 ! �/• FOR DEPARTMENT USE ONLY ry7 2 Application Accepted by Date ` .. ) Area / Pit or Grout Inspection by Date Final Inspection by Date ~� Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P O Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EH 13.24 IREV.tin 51 EH A-26 ' a fl o 0