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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468--34120 P O BOX 2009, STOCKTON, CA 95201 RERYIT EXPIRES 1 YEAR FROX_DATE ISSUED (Complete in Triplicate) Application is hereby trade 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. yJ Job Address 1 &ACE City Lot Size/Acreage Owner's Name ��Address &ACE Phone -- Contractor - n@Address MQS'. t— ose No.Y.9a_,9_ Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER El Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK �� SEWER LINES DISPOSAL FLD[��s�s7' G r ROP. LINE Z1115- FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ci Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing '}'Pi-{]omesticlPrivate *�-Gravel Pack Vi�-Tracy Type of Casing Scs9r- 7 Specifications FI Public fa Other n Delta Depth of Grout Seal _ PT- r Type of Groutffn= I I Irrivation ....._Approx. Depth I I Eastern Surface Saul Installed by �] Repair Work Done ❑ Type of Pump H.P. / 25 e State Work Done Well Destruction © Well Diameter Sealing Material & Depth (�1 Depth /yam, Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) 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 fel PKG. TREATMENT PLT.❑ Method of Disposal lq Distance to nearest: Weil Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ti Depth Size Number SUMPS U Distance to nearest: Well Foundation Property Line i DISPOSAL PONDS ❑ 1 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 ce ify 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 mia." The appl' st f all r i ctions. Complete drawing on to e side. �--�- Signed X Title: ate: FOR DEPARTMENT USE ONLY �y Application epted by Date43r—1A Area f+ 4 Pit �tiction by 1/ 2/ Final Inspection by Date f Q 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 INFO AMOUNT DUE AMOUNT REMITTED CK J1 ASH RECEIVED BY DATE PERMIT'ND. . EH 13'24(SM i/it 5) 00 Of + _c' EH 14•'16 UU 44 ,(