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APPLICATION FOR PERMIT N6r -' r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES N1()Wa��/� ENVIRONMENTAL HEALTH DIVISION `7 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PENIT RES 1 YEAR FROM DAT ID' (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. Job Address City/l fvt'�-.fa-t.. Lot Size/Acreage 112 d X� 5 C� Owner's Name kAne4 jjAddress �4 1 -S -- -- Phone (Contractor� ,F� I, Address 1AALicense No. hone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well L7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F} industrial ❑ Open Bottom C1 Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack - {-]Tracy Type-of Casing; -Specifications - I'1 Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout ` I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by S Repair Work Done 0 Type of Pump H.P. State Work Done_ WellDestruction ❑ Well Diameter Sealing Material & Depth t Depth AFiller Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIRIADDITION ESTRUCTION i I INo septic system permitted if public sewer is (/ J r available within 200 feet.) { E I Installation will serve: Residence it Commercial"_ Other � � t + Number of living units: Number of bedrooms f Character of Will to a depth of 3 feet:j V Water table depth ' SEPTIC TANK. ❑ Type/Mfg ' Capacity � i No.tCompartments PKG. TREATMENT PLT, ❑ -Method of Disposal Distance to nearest: Well Foundation Property Line t =LEACHING LINE Cl No. & Length of lines Total length/size f FILTER-BED CJ Distance to nearest: Well y Foundation Property Line SEEPAGE PITS 11 Depth Size t .,Number. ,'SUMPS Ll Distance too nearest: Well Foundation Property Line -DISPOSAL PONDS ❑ �---^�'^`'"'.."„ •_= -- I hereby certify that I have prepared this'.application and that the work willbe done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County; 9 t 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-con0acting signature G' 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 componsa- i lion laws of Cailfornia." Lo- t The applicant must call for allZL-A ed inspections. Complete drawing on reverse side. 1 s Signed x_f , !"/_ Gvao-_ Title: _d, t le a _.6.1',�a-t/� Date: `-i`' FW DEPARTMENT USE ONLY Appiioetion Accepted by 1Z. 4A 4 Date Z Area wPit or Grout Inspection byDate Final Inspection by Data I Additional Comments: - - `Applicant - Return all copies to: Sae Joaquin County Public Health Services, Environmental Health Permit/Services ( 1601 E. Hazelton Ave., P O•,Box,200.9,. Stockton„CA• 95201 f ` FEE OUNT Dt1E '; AMOUNT REMITTED CK RECEIVED BY DATE.._ PERMIT•NO. INFO a r`yi CASH EH 13-26 IR EV.iinSls' / '�^'t PC- �� .s �'�.. � -2- EH b2a LUa