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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 BOX 2003,- STOCSTON, CA 95201 EBMIX EXPIRES 1 YEAR FROM DAT ED (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. Job Address �� ` �``y a e City� Lot Size/Acreage 6 f/ i Owner's Name r Address ``'rt'` Phone 7-1 vlo Contfactor6, Address - } License No4 L_f'ttone ,TYPE OF WELL/PUMP: WELL ❑ WELL REPLACEMENT ❑ -DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION El SYSTEM REPAIR ❑ ,.OTHER ❑ Monitoring Well ❑ ABY DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL =_— .PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 17 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'I Public 1-1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation ....,....Approx. Depth € 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 s, Depth t T Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I,.I REPAIR/ADDITION f I DESTRUCTIONX iNo septic system permitted if public sewer is w € available within 200 feet.) Installation will serve: Residence—_ -C_"M -VIcial— Other # Number of living units: Number of?bedr6oms c Character of sail to a depth of 3 feet: Water table de th SEPTIC TANK. ❑ Type/Mtg {{ f Capacity No. Compartmbnts PKG. TREATMENT PLT. ❑ t i Method of Disposal Distance to nearest: Well Foundation Property Line .err, a'F LEACHING LINE LD . No. & Length of;lines Total length/size > FILTER BED ❑ Distanceto nearest`" 'Weil a--- Foundation Property Line l SEEPAGE PITS 11 Depth Size r" ,Number SUMPS L) Distance to nearest: Well Foundation Property Line f DISPOSAL PONDS ❑ - V 4 s t I hereby certify that I have prepared this application and that the work wilt be done in.accordance with San Joaquin couhty 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 i employ any person in such manner as to become subject to workman's compensation laws of California,"Contractor's hi4g 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 tic 11 for all'zequire ns tions:-Complate-drawing on,reverse.side:, »,,..�. -•-�^+�- � Signed X Title: �fl - ' Date: .. FO EPARTMENT USE ONLY o Application Accepted by Data Area Pit or Grout Inspection by _ Date Final Inspection by DataC1� Additional Comments: • U f 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 INFO FEE AMOUNT DUE OIJNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. f . EH 13-24(REV.I I R 51 --)4, 0 2 Y EH 14 �}�)25 t " r Q� 1r 1- + �� /�