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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468--3420 P O BOX 2009, STOCKTON, CA 95201 PENIT EXPIRES 1 YEAR FROM DATE ISSUIP (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 County Public Health Services.,r Job Address v0114 City hot Size/Acreage Owner's Name r� PIP/C-e_- Address G,� f/' � — Phone 4_. Contraactor�^ L.� �.16� GAddress 18o License No,a l •�-Phone _.� TYPE OF WELL/PUMP:-- - NEW WELL ❑ WELL REPLACEMENT C] DESTRUCTION ❑ out-of. Service Well L-f i - 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 . D Industrial a ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing [_l Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications � I'] Public is Other n Delta Depth of Grout Seal Type of Grout I i Irrigation.- v Approx.Depth I I Eastern Surface Seal Installed by i —Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction © Well Diameter Sealing Material & Depth 7. t- Depth - Filler Material !-Depth TYPE OF SEPTIC WORK:,- NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other i Number of living units: Number of bedrooms rCharacter of soil to a depth of 3 fest: `{ _ Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ n Method of Disposal +_ Distance to nearest: Well Foundation Property Line lJl7 LEACHING LINE tet' No. & Length of lines !Total length/sire _ FILTER BED ❑ Distance to nearest: Well 1601 Foundation — Property Line SEEPAGE PITS I� I/Depth #� -- _Sire�� is Number r t SUMPS Lt Distance to nearest: Well _je ` Foundation . Property Line 16�— 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 work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all re fired inspections. Complete drawing on reverse side. A Signed X 01 Title: � Date: OR ART NT U5 ONLY Application Accepted by Dat10, e Ar a Pit or Grout Inspection by Date Final Inspection by Dated Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health f Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box'2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. V INFO CASH EH 13.24 MEv.1 i x S) 1( 14EH14-16 1