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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 IS$UED (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 (6Jy&:g& � _ _ _ Cit t Lot Size/Acreage vG/`l Owner's Name Address 6 ��,�-e�" `� �''u' -- -- Phone - 3 Contract Address ��. License No. ZS'2 7_61 Phone a`Sl TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well .❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES "` DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca .N-� Dia. of Well Excavation" Dia. of Well Casing ' FI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing .: Specifications j I'I Public El Other i1 Delta �� Depth of Grout Sea! ` Type of Grout I I Irrigation _..Approx.�Depth I 1 Eastern -Surface Seal Installed by Repair Work Done U T p p Type of Pum H.P. ► State Work Done _ Well Destruction ❑ Well Diameter Sealing Material .&:D epth Depth f Filler Material b Depth CP TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I-(No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Rel"ce�' Commercial Other Number of living units: Number of b rooms n Character of soil to a depth of 3 feet: Water table depth f1 SEPTIC TANK. Type/MfgCapacity No. Compartments PKG. TREATMENT PLT. ❑ � � � Method of Disposal Distance to nearest: Well 511Q Foundation 7:� ^P!operty Line LEACHING LINE No. & Length of lines Total length/size r r FILTER BED ❑ Distance to nearest: Well S—W Foundation_,._.�_ Property /f Line .-� Li 4 r d SEEPAGE PITS Number f SUMPS mid' Distance to nearest: Well ZZ26 Foundation Ta , 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 laws, and rules and regulations of the San Joaquin, County y Homs 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 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 m call tot a r u' d inspections. Complete drawing on reverse si a. Signed X Title: Date: 67 FOR DEPARTMENT USE ONLY App' tion Accepted by Area r Grou Ins action by at Final'Inspection by " (rc►s� Dat 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 INFO AMOUNT DUE AMOVN7 REMITTED CASH n RECEIVED 8Y DATE PERMI N0. . EH13.21(REV.L/N 5 EH t4•2e