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APPLICATION FOR PERMIT x SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PRAMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made.to San Joaquin County for a permit to construct and/or install the vork 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 Servic Job Address E XyfiZ e,4,0 City esco4Z1 Lot Size/Acreage Owner's Named Address Contfactor �^' ��` dress lD�t�o E'��D License Na.411' 3Z0 3 PhonedY7 Syf~ TYPE OF WELL/PUMP: / NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION D Out of Service Well ❑ PUMP.INSTALL.ATION)<— SYSTEM REPAIR C1 OTHER ❑ (Monitoring Well L7 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 d ) F) Industrial ❑ Open Bottom ❑ Manteca pia. of Well Excavation Dia. of Well Casing D'Domestic/Private Cl Gravel Pack 0 Tracy Type of Casing Specifications I'1 Public El Other fl Delta Depth of Grout Seal Type of Grout I 1 Irrigation —Approx. Depth - I I Eastern Surface Seal Installed by Q Repair Work Done 0 Type of Pump C .6 H.P. _S_ State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler material 5 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I lNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms c Character of soil to a depth of 3 feet: Water table depth �n SEPTIC TANK. ❑ Type/Mfg t Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal r Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line 3 SEEPAGE PITS 11 Depth Size Number SUMPS Cl Distance to nearest: Well Foundation 4 Property Line DISPOSAL PONDS 0 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 atles4nd regulations of the San JoaquiniCounty I 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 parson in such manner as to become subject to workman's compensation taws of California."Contractor's hiring or sub-contracting signature certifies the follo 'ng: "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 C if nia." The applica ust 11 for al u ins clions. Complete draZonnseside.Signed Ti ✓ Date: goT USE ONLY Application Accepted byDate res 1 16 Pit or Grout Inspection 1 1 Pe b Y Date Final Inspection b Date —Z0 d Additional Comments: �r Applicant - Return all copies to: San Joaquin County Public Health z Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 ,NFO( AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. P i + EM 13-24(REV.Iinsl �� a� 0 C) dq.