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f APPLICATION FOR PERMIT SAN J'OAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PEMIT EXPIRES 1 YEAR FROM DATE IS$ 7UED^ " (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 1962 and the Rules and,tiegulations of_San Joaquin County Public Health Services. rI r Job Address 'e A0 City RL{61711 Lot Size/Acreage 1 f.. Owner's Name TGWi to 6 u 1�2k-it- Address �� Phone Contfactor cAddress License No. Phone w TYPE OF WELL/PUMP: N. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 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 Cl Industrial r ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing FI Domestic/Private + ❑ Gravel Pack Ll Tracy Type of Casing lAL. Specifications F] Public # Ia Other n Delta Depth of Grout Seal Type of Grout I I Irrigation t _.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material & Depth i Depth t Filler Material & Depth I TYPE OF SEPTIC WORK: NEW INSTALI,RTION REPAIR/ADDITION I I DESTRUCTION I 1>fNo septic system permitted if public sewer is Q t / available within 200 feet.i Installation wilt-serGe:i-Residence 1=/ Commercial_ Other a Number of living units: � �'4 Number of bedrooms Character of soil to a deLpth of 3 feet 1 42&ng& l/i.' Ko '3 Water table depth 0 SEPTIC TANK. Cr' Type/Mfg 4' Aj L Cnn"x,,,4e_ Capacity �,� o No. Compartments PKG. TREATMENT PLT, ❑ f r , Method of Disposal Distance to nearest: Well_ �'� Foundation_ --- Property Line� Q l LEACHING LINE ; No. & Length of lines Total length/size FILTER.BED C] Distance to nearest: Well lol Foundations Property Line �n r ;1"z SEEPAGE PITS ['I Depth R Size _ Number SUMPS LI s 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 taws, and rules and regulations of the San Joaquin County y1 r 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 work for which this permit is issued,-.I-shall employ persons subject to workman's compensa- tion laws of California." I ? The applicant must call for all req d inspections. Complete drawing on reverse side. Signed X Titles Date: f A FOR DEPARTMENT t15 taNLY Application Accepted by a Date /lJ r Area t Pit or Grout Inspection by Date Final Inspection.by , Data 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 FEECK11 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY s DATE PERMiT NO. t . EK 13.24(REV,tin5l- �V �� d'�L .Cr + q5_ C/ tJ l