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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 2009, STOCKTON, CA 95201 PFAMIT EXPIRES 1 YEAR FROM DATE i (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 Z City 4ECG?GBAJ_ hot Size/Acreage Owner's Name Address Phone ff-4g— i i Contractor F 12Xb &ZW..D.._Address 7 Ah 4 R License No. 4�yf�7A __Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE f FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'l Public 1-1 Other 11 Delta Depth of Grout Seal Type of Grout I I Irrigation Depth I I Eastern Surface Seal Installed by i Repair Work Done 0 Type of Pump k H.P. State Work.Done Well Destruction O Well Diameter Sealing Material & Depth i Depth Filler Material & Depth TYPE OF SEPTIC-WORKi ,NEW INSTALLATION REPAIR/ADDITION i I DESTRUCTION I i INo septic system permitted if public sewer is - _ available within 200 feet.] Installation will serve: Res��i��dence ✓ Commercial_ Other Number of living units: __..L Number of bedrooms Character of soil to a depth of 3 feet: 'SAL2DY L.4 Water table depth SEPTIC TANK ❑ Type/Mfg PI-L Capacity No. Compartments Z PKG. TREATMENT PLT. DMethod of Disposal e , Distance to nearest: Well fad Foundation._,�,_.v .�.,.._ PropPropertyy Line LEACHING LINE No. B Length of lines Op Total length/size "�- FILTER BED ❑ Distance to nearest: Well 4261"li- Foundation ?,O' Property Line ,Z . SEEPAGE PITS l Depth yr r Size Number~- SUMPS LI Distance to nearest: Well�+�` Foundation /00'Y� Property Line DISPOSAL PONDS Cl 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, I shall employ persons subject to workman's compensa- tion laws of-California." The applicant must call for all required inssppeections. Complete drawing on reverse side. Signed X� Title: [.e's�^'�� Date: 4" FO=P�!eT U5E ONLY Application Accepted.by Date Area !y Pit or Grout Inspection by Date Final Inspection b Dete/ Additional Comments: 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 FEE I AMOUNT DUI: AMOUNREMITTED CK INFO RECEIVED BY TS PERMIT'N0. . EH 13-24 IREY.I/M 51 EH TL2b I4