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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-8420 ' P O BOX 2009, STOCKTON, CA 95201 d RMITEXP RES 1-YEAR FROM DAT ED (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 Countyi Public Health Services. Job Address _1 p ©91 1C DOE::b City Lot Size/Acreage Owner's Name Address Phone Contractor 'oi L. 'Address?6 7x t�E fyl?✓A3 5— License No. V �f1�t Phone_ _3, TYPE OF WELL/PUMP. NEW WELL ❑ WELL.REPLACEMENT [I DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ""„"DISTANCE-TO-NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO.' —PROP:-LINE f FOUNDATION ` AGRICULTURE WELL+, ' ' OTHER WELL PITSISUMPS INTENDED US£ TYPE OF WELL PROBLEM AREA GON5TRUCTION SPECIFICATIONS - t1 n Industrial ❑ Open Bottom ❑ Manteca Dia. of.Well Excavation Dia. of Well Casing ^` i JX Domestic I Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications. I'1 Public f-1 Other fl Delta Depth of Grout Seal Type of Grout ,F i I Irtioation _.Approx, Depth I 1 Eastern Surface Seal installed by f Repair Work Done 0 Type of Pump<,cim R5i4rC H.P. 2' State Work Dona _ Well Destruction .❑ Well Diameter Sealing Material 6 Depth i Sw.�.. 5 = Depth Riker Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION i I DESTRUCTION I I INo septic system permitted�if`public sewer-is " available within 200 leet.i" Installation will serve: 'Residence_ Commercial _ Other .� Number of living units: Number of bedrooms Cheracter`of soil to a depth'of-3 feet: Water table depth 4J � SEPTIC TANK. ❑ Typ3l.Mfg Capacity No. Compartments a_ i - PKG. TREATMENT PLT. ❑ I Method of Disposal _ Distance to nearest: Well Foundation Property Line LEACHING LINE L1 No. & Length of lines Total length/size •f I FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Lina 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 e 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 fol wing: "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 applican must call tat al're require inspe ti ns. Ca fete drawing (1,Ii reverse side. 5lgned ! C.i✓. Title: 2�i: -- Date: DEPARTMENT USE ONLY Application Accepted by [_-�"t_C1./l Date Area Pit or Grout Inspection by Date Final Inspection by� a[e Additional Comments: h ` 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 AMOUNT REMITTED C K RECEIVED BY GATE PERMIT'NO, ♦ SH EH 13.24 IREV.i,H5) `-'~� EH 14.28 j_� _