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APPLICATION FOR PERMIT NVW SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 4 ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES l YEAR FROM DATE ISSUED 4�'2_ lb (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. ��Ztoe_ Job Address City 6fnmopt Size/Acreage Sr�p m0 Owner's Name " Address ?5 Y-� C IF'C13?4n 42 Phone l r 6s Contractor Address License No. Phone TYPE OF WELL/P MP: NEW WELL ❑ WELL REPLAC MENT ❑ DESTRUCTION ❑ out of Service Well EY PUMP INSTALLATION ❑ SYSTEM REPAIR L1 OTHER ❑ -Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private Cl Gravel Pack 0 Tracy Type of Casing Specifications i'l Public CI Other n Delta Depth of Grout Seal Type of Grout I I Ifrigation __ Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done L7 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTIONINo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms v Character of soil to a depth of 3 feet: il Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS It Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS El 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 cartifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to wo(kman's compensa- tion laws of California." The applicant st telt for all repo' petion . 0 complete drawing on reverse side, S IF Title: ,..._ Date: J FOaEPARTMENT USE ONLY Application Accepted by ✓ Date �_7` I C� Area Pit or Grout Inspection by Date Final Inspection by .5-1 Date"/� «� 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 INFE A�M+OUNNTT DUE AMOUNT REMITTED CA RECEIVED BY DATE PERMIT NO. . EH 13.24)REV.I/116) EH;�•2e `