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APPLICATION FOR PERMIT SAN J'OAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 � P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made.to San Joaquin Count for PP Y q y permit to construct and/or install the work herein described. This i application is trade 1n compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job AddressZ-77001 1 C� /S An , City`_�)k��t't7�(/ Lot Size/Acreage �d � Owner's Name �� Address Phone Contractor Address_ eoo ! _ _ License NoT? -jr Phone f TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION. SYSTEM REPAIR El OTHER ❑ Monitoring Well C7 i DISTANCE TO NEAREST: SEPTIC TANK _ Gk3 SEWER LINES DISPOSAL FLD.IrO PROP. LINE _y FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL„.=, PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial 0 Open Bottom ": ID Manteca Dia. of Well Excavation Dia. of Well Casin Domestic/Private WGravel Pack El Tracy Type of Casing Specifications YFo r I'1 Public El Other IWI Delta Depth of Grout Seal Type of Grout I i Irrigation 'L.VQ_.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump — H.P. Z _,. Q7J�- S 7C State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth T �� Depth Filler Material & Depth - TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR1,ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is s available within 200 feet.) Installation will serve: Residence— Commercial Other•' - 4 . Number of-living units: LL=-z-—-Number of bedrooms- 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 nearest: r Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: i Well Foundation Oroperty Line i ' t SEEPAGE PITS 11 Depth, - t Size �`F' - -`" Number SUMPS LI Distance to nearest: r Well Foundation Property Line DISPOSAL PONDS ❑ % i 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 f 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 subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued;1 shall employ persons subject to workman's compensa- tion laws of California." The applicant rrity tail for all required inspections. Complete drawing on reverse side.Of r Signed X Title: -- Date: 4*01-X--QJ I FO EPARTMENT USE ONLY Appli �ccaptad by Date b •" �'"�� Area CZ Pit r Grout ;no ction bVI_E __,•_• Date f��-�G Final Inspectioin by Date ! - Additional Comments: f 1 S it epi 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 IJtJE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO, 3 r�� 3� 9 �- 7zw EH13.211REV.r/h5) , i u- -L� b .tel �� 3 19 EH;4.� IJ .-OS'fb