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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 PERMIT EXPIRES 1 YEAR FR9M DATE ISSUED iI (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 CountyPublicHealth Services. Job Address r 3 7 SG1W^-4F®T City "`G� L Lot Size/Acreage S�C Owner's Name Address Phone Contractor 4t;6 'i'+ (��5 _Address a I3&Y OF License Nal. Phone 7L 9-: TYPE OF WELL/PUMP: _ NEW WELLN WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION,9 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK r SEWER LINES r- -1 - DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL- -. ,OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L) Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation,. / Dia. of Well Casing y.�Domesuc/Private Gravel Pack ❑ Tracy Type of Casing /w� T^S`+ Specifications i'1 Public i CI Other # fl Delta Depth of Grout Seal -T.ype of Grout C AA 0 A- 7 I 1 Irrigation 'L'La _Approx. depth I I Eastern Surface Seal Installed by - 11L. ` Repair Work Done ❑ T �"� ype of Pump � H.P. _'Z State Work Done' Well Destruction ❑ Well Diameter Sealing Material & Depth _h {�pth Filler Material S Depth < TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRlADDlTION ! I DESTRUCTION`l',I.[No septic system peimitted,if publili c sewer is,r } available within 200 feet.1 \^ Installation will serve: Residence Commercial_ , Other Number of living units: s Number of bedrooms Character of soil to a depth of 3 feet' j 4 Water table depth w r. SEPTIC TANK.- ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size - \ FILTER BED CI Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1.1 Depth Size Number SUMPS El Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work wilt 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 comp'ensa- tion laws of California." I The applicant must all f r all r aired inspections. Complete drawing on reverse side, q Signed X i. Title: �_ Date: 7L:—J-- _ F DEPARtzz TMENT USE ONLY Application Accepted by Date �)- ,1,_ Area Z_ Pit or to •Inspection`by Date ! Frinal Inspection�by. f� E ate � Additional Comments- Applicant Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services IRIA 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201FEE i INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMiT'NO. . EH t3.24tAsv.,,wsl 1,34 "paF1, I .o F1._ 1