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APPLICATION FOR PERMIT } - ' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ( t� ENVIRONMENTAL HEALTH DIVISION `f 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOR 2009, STOCKTON, CA 95201 PT"IT EXPIRES 1 YEAR FROM LATE ISSUED .1�?�V✓' .. .� , (Complete its Triplicate) Application is hereby made to Saw �Joaq C unty for a permit to construct and/or install the work herein described. This application is made in compliance withSanJoaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin CoPUWC Health Services. -* , ,, NOCz Job Address APw 0:11 - 001�4I L;ta bin Ur tkaae City Lot Size/Acreage 5 WGra rv�p v�- p C�ll�Lt,r- Mo dt4 r la_•.f we.,l sc-w �e 3 a o Owner's Name Te-I f 01064 C�om�4dn J__ Address s4-c r.-A Z Phone Contractor -� Address ZSZS"C. A�tr'�k _ License No. S t Z,7-V g Phone to S�$Z E Z TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION CI Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER �y7p� / nitoringWell C7 / �7pr4�4�F�1.CKK DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I- so, p_, FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 11 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS l C Industrial ❑ Open Bottom ❑ Manteca Dia. of JNe" Excavation (.�` Dia. of Well Casing 5 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1'1 Public 1.1 Other ❑ Delta Depth of Grout Seal `-�� Type of Grout r�1__M i I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L] 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 f I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if ptiblic sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms FN Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to near I est' Well Foundation Property Line F r LEACHING LINE L1 No. & Length of lines Total length/size a FILTER BED ❑ 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 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 certify that in the performance of the worts for which this permit is issued, I shall employ persons subject to workman's compansa- tion laws of Califo " The applicant ust II for all required to C mplete drawing on reverse side. Signed y Title: _ Date: 10 F D ARTMENT USE ONLY 'moi Application Accepted by Date Area - wzzy Pit or Grout inspection by Date Final Inspection by Date L (tom Additional Comments: i Applicant - Return all copies to: San Joaquin County Public health Services, Xnvironmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEEi AMOUNT DUE AMOUNT REMITTED RECEIVED 8V DATE PERMIT N0. INFO XUA ^� + EH13.24(REV.1/As) EH 114-25 G7 1 "�-�r.� �i` O n' 1,aA i