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APPLICATION FOR PERMIT k' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - V ENVIRONMENTAL HEALTH DIVISION 1 ` :1601 E. HAZELTON AVE. , PHONE (209)468--3420 i P 0 BOR 2009, STOCKTON, .CA 95201 _ PERMIT EXPIRES 1 YEAR FROG DATE IS$LED (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. �.._ d Job Address jpa E ,City V M Lot Size/Acreage Owner's Name /� .PSGCN ---- Address Cy /r// IJ�L�1� Phone .- , Contractor r Address License [Va37PhoneTa 99 TYPE OF'WELL/PUMP: NEW WELL' WELL REPLACEMENT ❑`' DESTRUCTION/Out of Service Well 0 _ PUMP INSTALLATION Z SYSTEM REPAIR 0 ! OTHER 13Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK Sf SEWER LINES DISPOSAL FLD. PROP. LINE ' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS `7 C] Industrial �d'Open Bottom ❑ Manteca Dia. of Wail Excavation Dia. of Well Casing Domestic/Private O Gravel Pack ❑ Tracy Type of Casing �' Specifications I'l Public 1_1 Other n Delta Depth of Grout Seal Type Type of Grout 11 Irrigation —.Approx. Depth 11 Eastern j glace Seal Installed by Repair Work Done B. Type of Pump SC[� H.P. � � - State Work Done Weil-Destruction Well Diameter Sealing Material & Depth � ' Depth . Filler Material & Depth ho IV Ap TYPE-OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I I (No septic systam permitted if public sewer is available within 200 feet.l Installation will serve: Residence— Commercial____ Other Ct Number of living units: , Number of bedrooms �7 Character of soil to a depth of 3 feet: Water table depth j= SEPTIC TANK O Type/Mfg a Capacity No. Compartments PKG, TREATMENT PLT, ❑ Method of Disposal T Distance to nearest: Well Foundation. Property Line LEACHING LINE Ll No. & Length of lines Total length/size FILTER BED E❑ 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 Iaws_, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature cenifies 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." t The applicant'j mus call for all required ins Ctiona. Complete drawing on reverse side. y � I Signed Title:. Date: _- Application AccF-O--R DEPARTMENT USE ONLY e ted bYDate ,a Area Pit r J .....��.._ Pit or Inspection ' -�� Date `4�' t�ec on by Dat Final Inspection by �� Additional Con, +�s - 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 c FEE CASH DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. q a. �� + EH 13.2 rREV.tin51 � r, ` Eli^,!-Ili t OrD df2 0 cy J C) #1 WAS