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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)465-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FRAM DATE ISSUED � (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 ( 1 5 �� /�� C 1 C-1ity Lot Size/Acreage x Owner's Name (,YfL�1rIe-5 C2 �_ Address So" e, Phone S'- 1-28 ~ 43e.1 ��ZoS Contfactor � Address - License No. Phone r TYPE OF WELL/PUMP: NEW!WELL ❑ WELL REPLACEMENT D DESTRUCTION ❑ Out of Service Well ❑ j } /PU4P INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLU. PROP. LINE Q FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i 4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS jV n Industrial D Open Bottom ❑ Manteca I Dia. of Well Excavation Dia. of Well Casing 1 ❑ Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications I'1 Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout I I Irri ation A " 0' Approx. Depth I ) Eastern Surface Seal Installed by " Repair Work pone ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR LADDITION.i 1--DESTRUCTIONIkA INo septic system permitted if public sewer is 1 \ vailable within 200 feet.) r Installation will sere: Residence Commercial_ 'Other . Number of living units: Number of bedrooms t I Character of soil to a depth of 3 feet: Water table depth 1 SEPTIC TANK. ❑ Type/Mfg f Capacity r No. Compartments PKG, TREATMENT PLT. 0 1 Method of Disposal / . _ Distance to nearest: WellFoundation Property Line LEACHING LINE Wit' ❑ No. & Length of lines Total length/size FILTER BED C1 Distance to nearest: Well Foundation Property Line s SEEPAGE PITS 11 Depth/ Size Number SUMPS ' D Distance,to nearest: Well Foundation Property Line DISPOSAL PONDS D 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, f shalt employ persons subject to workman's compensa- tion laws of California." The applicant must al r all required inspections. Complete drawing o se side, y� �^ G Signed X ,/1, .. . _ _ Title: ' +r Date: f S J V F D RZh USE ONLY Application Accepted by Dae *r � 6-4d4l-Sig Pit or Grout Inspection by ate Final Ins ection by r✓ 4-- Applicant �r� �- Additional Comments: - Return all copies to: San Joaquin County Publ Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED I K 0 CASH RECEIVED BY DATE PERMIT'NO. . EH 13-24(REV.r/A5y {� L ! `Q EH 14.2E �f �! I a 'O 110