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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 pERKII EXPIRES 1 YEAR FROM DATE ISSUM (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. h + .5� — L City Lab+ _ Lot Size/Acreage 'L� Job Address n I S G M L Phone q 3 !9 Owner's Name A""^r `�A'AQ b 0 Mt _ Address 17$ '377 3r Phone 33 Y-y2tr Contractor G�+� (SkIDSS Address /�46� License No. TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ out of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L7 F DISTANCE TO NEAREST: SEPTIC TANK �D+�+__ __ SEWER LINES ! n DISPOSAL FLD. PROP. LINE�`�J ,. t FOUNDATION AGRICULTURE,WELL OTHER WELL 00-- _. PITS/SUMPS "- ^- _INTENDED USE _TYPE OF WELL�. -PROBLEM AREA 'CONSTRUCTION SPECIFICATIONS f� industrial i 0 Open Bottom © Manteca Dia. of Well Excavatio � "Dia"of Well Casing YF� Domestic/Private Gravel Pack 0 Tracy Type of Casing Specifications I VI Public Cl Other 11 Delta Depth of Grout Seal _/aV Type of Grout r i I Irrigation l "LOPDZ.Appfou. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump T.!— H.P. _ State Work Donees t� Watt Destruction ; ❑ Well Diameter Sealing Material & Depth Filler Material b Deptht Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I i DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) t i Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms l Character of soil tp a depth of 3 feet: Water table depth f SEPTIC TANK } ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT, C) Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE D No. & Length of lines Total lengthtsize FILTER BED t C) Distance to nearest,,9 .)-Well Foundation Property Line SEEPAGE PITS f f I Depth x Sizer' Number SUMPS t El Distance to nearest: Well t~ 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 laws, anc rules and-regulations of the San Joaquin county I- ' Home owner'or licensed agent's signature Certifies the following: "Iicertify that in the periormance of the work for which this permit is issued, l 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 pertormance�of the work fdr which this paimit is issued, 1 shall employ persons subject to workman's compensa- tion laws of-California." { ? The applicant must call t r all required inspections. Complete drawing-fon reverse side.«'^�� i __ Signed X Title. fll� —. � Date: t: FOR DEPARTMENT USE ONLY Application Accepted by - Date_-• / Area ?/ _ .� L_Fi"l-Ingped Fo, Date _ Pit Grout I pection btu �► ^ Date Y Additional Comments: Applicant - Return all copies t : San Joaquin County Public Health Services, Environmental Health Permit/Services 1 1601 E. Hazelton Ave., P O'Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMtTTED CK# RECfOVYD BY DATE PERMIT NO. INFO / ,n,1 1CASH /j�/ ��[� [% j� EH 13.2401 Ev.+/N61 /,� ` Y-•c+C! L!,`C�¢G GI r• ' EH i4•Z8 I —[ 4 '71 7 �SF