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i APPLICATION FOR PERMIT 1 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION v1 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) i 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 ervices. / Job Address / 7,,A1- �s[9 � City l Lot Size/Acreage71.6 Owner's Namepl L.YS Address ( ✓ ` ^ �� Phone Contractor �� S Q Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑��.._- WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ Monitoring Well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ❑ DISTANCE TO NEAREST: SEPTIC TANK k SEWER LINES e DISPOSAL FLO. PROP. LINE FOUNDATION r AGRICULTURE WELL - OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM.AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Ca Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ('1 Public (:1 Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation _.Approx. Depth I I Eastern ; "" "Surface Seal-Installed'by Repair Work Done 0 Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter 3 Sealing Material & Depth Depth r Filler Material & Depth r TYPE OF SEPTIC WORK: NEW INSTALLATION I I ! REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is #available within 200 feet.) Installation will serve: Residence_ Commercial_ Other r Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: } Water table depth SEPTIC:TANK O Type/Mfg Capacity No. Compartments PKG,;.TREATMENTPLT, ❑ 1 Method of Disposal Distance to nearest: Well Foundation' Property Line Ili LEACHING LINE ❑ No. & Length of lines t Total length/size ` FILTER BED ❑ Distance to nearest: Well Foundation Property Line r. l/ SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ tt 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 r 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 i performanci of the work for which this permit is issued_, I shall employ persons subject to workman's compensa- tion laws of California." G The applicant�mall all require i omplete drawing on re erse side. Signed X "Tile: r 'r ►_r+va-J� Y ° Date: li DEP TMENT USE ONLY c� _ Application Accepted by Date �- a� � Area Pit or Grout Inspection by Date Final Inspection by Date I / 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 INFO AMOUNT DD�7U'^^Epp AMOUNTREMITTEDCK H RECEIVED BY FFEE DATE PERMIT'NO. I . EH 13.24 IREV.1/851 EH e1-26 AA..