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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 PERMIT EXPIRES 1 YEAR FROM DATE-_SSuE,� (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 vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public ealtrh 8e ices. ' Job Address 7 & City Lot AV 4 Size/Acreagei,-- � DAddress Owner's Name Phone Contract -e ___ or Address-)0'a 24 7 License No. Phone 36L90—" TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Ll Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLU, PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ^�` ~ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f_1 Industrial ❑ Open Bottom ElManteca Dia. of Well Excavation Dia. of Well Casing [I Domestic/Private ❑ Gravel Pack D Tracy Type of Casing Specifications I'i Public 1-1 Other n Delta Depth of Grout Seal Type of Graut I I Irrigation _ Approx. Depth I I Eastern Surface Seat installed by Repair Work Done 0 . Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth r Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATIO REPAIR/ADDITION i I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) d Installation will serve: Residence! Commercial .—Other Number of living units: —/— Number of ooms ,y�,? Character of soil to a dap of 3 feet: Water table depth F/A/ r SEPTIC TANK.t Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.C7 Method of Disposal (Q &V Pro l ,. Distance to nearest: Well Foundation party Line LEACHING LINE No. & Length of lines '' To?l length/size e—) FILTER BED CI Distance to nearest: Well Foundation Property Line fr SEEPAGE PITSDepth $ Size Number SUMPS . = LI• Distance to nearest: Well ZA2Z2 Foundation Property Line :S: DISPOSAL PONDS ❑ I hereby certify-that-1"have_pre.pared 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 Howie 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 of sub-contracting signature certifiai'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 applicantt call for all uir d inspections. Complete drawing on reverse side Signed TitW Date: t _FOR DEPARTMENT USE ONLY j `� Application Accepts Date Area by Pi r Grout Inspection by "t0ate i v Final Inspection by Date �a f I Additional Comments: Applicant -- Return all copies to: San Joaquin County Public Health f Services, Environmental Health Permit/Services !� r 1601 E. Hazelton Ave., P 0 Box 2009. Stockton, CA 95201 y+r rf PO �'`,.AM_ OUNT DUE AMOUNT REMITTED CK 0 CASH RECEIVED BY DATE PERMIT'NO. + EH 13724MEV.irns� O Q EH-31-2a '� 9 1 x