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APPLICATION FOR PERMIT • r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ` ENVIRONMENTAL HEALTH DIVISION / 1.601 E. HAZELTON AVE. , PHONE (209)468-3420 / P O BOX 2009, STOCKTON, CA 95201 �fa`7 ERMIT EXPIRES 1 YEAR FROM DATE ISSUED � n (Complete in Triplicate) c Application is hereby made to San Joaquin County for a permit to construct and/or install the Work herei Ud�r e . This ' application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San J n County Public Health Services. c�� Job Address I7 �� S. a �� - City SL_A�,Zu Lot Size/Acreage Owner's Name Address Phone ContractorLT-.,b7,:!� &r Address a7 rW&K License tZo. z{ X4,5 Phone 3 %2 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C_l DESTRUCTION JrCut of Service Well ❑ PUMP INSTALLATION ElSYSTEM REPAIR ❑ OT p Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE: WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing CI Domestic/Private ❑ Gravel Pack L7 Tracy Type of Casing Specifications I'I Public E:1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _..Approx. Depth I I Eastern Surface Seal installed by Repair Work Done U 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 I I REPAIR/ADDITION I I DESTRUCTION INo septic system permitted if public sewer is vailable within 200 feet.I 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 r Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size C FILTER BED CI 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 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,-1 shall employ persons subject to workman's compensa- tion laws of California." The applicant mu all for all required inspections. Complete drawing on reverse side. Signed X Title: IQ�u z2f ems. � Date: &-6,3 FO TMENT USE ONLY Application Accepted by `(na4�. t1La __ — A=�=-� Date Area —7 Pit or Grout Inspection by Date Final Inspection by � Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Servicee 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 INS MOUNT DUE AMOUNT REMITTED CASH r RECEIVED BY DATE PERMIT NO. : EH 13'24 IREV.I/a 5s - _D tom, J�`��j o `�'u 9� EH Z4-2e L r a /` �� !y