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f APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES s ENVIRONMENTAL HEALTH DIVISION 1.601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM 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 Joa4Nin Count Ordinance No. 549 a l$62 and the Rules and Regulations of San Joaquin County Public Health Services. 01-p �$ J`'C�uTfj/� `✓ c3�G ,UAL Jab Address __ __ � City I'V /J^lt�Lot Size/Acreage Owner's Name Address .t F �Z—Ori,c/� --V�JP> Phone _Contracto �<� . .6�Address_� �� _� License�Va� /i �Phane �T-XPE•Of-WELI!•PUMP,.., ,,NEW-WELL d,_.- ��WE-6L-REP_L-ACEMENT-[J- ,,.,.. DES.T.RUCTION-0-Out of,Service-Well.._❑_ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL t PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS_ + y C-) Industrial C1 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of'Well.Casing CI Domestic/Private ❑%Gravel-Pack—C-]Tracy--•- �---Type•of,Casing—�-- f Sifications I'I Public f"1'-Other 11 16 pec Delta Depth of Grout Seal Type fi Grout 1 Irrigation .Approx.IDepth I I Eastern Surface Soul Installed by Repair Work Done D Type of Pump. H.P. 1 -State Work-Done Well Destruction 0 Well Diameter Sealing Material A Depth f f �^Depth Filler Material b Depth. TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION, DESTRUCTIOW1 1 iNo sdptic'system permitted if public sewer is Iavailable within-200 feet.l Installation will serve: Res !'*�`Bence Commeicial_Other""""-'"""'"'•'^"--1 Number of living units: J .__ Number of bedrooms t Character of soil to a depth of 3 feet: r Water table,depth SEPTIC TANK. ❑., T elMf ' � - ?' �' -" "�' Y� g Capacity " y No. Compartments PKG. TREATMENT PLT. ❑. %� `•ti � �I r a Method of Dispbsal *+, e a gistance do nearest: Well' Foundation Property Liner ! LEACHING LINE D No& Length of lines _ Total length/size ' FILTER BED CI Distance to nearest: Well Foundation -Property Line' t j SEEPAGE PITS 11 Depth —Size _ Number SUMPS Ll Distance to nearest:` t Weil! Foundation Property Line i DISPOSAL PONDS D 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, �,, 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 of sub-contracting signature certifies the following: "I certify tha6n the performance of the work,for,which this permit is issued, !'shall employ persons subject to workman's compensa- tion laws of California." k ' a i _ tk The applicant must call for 0 require inspections. Complete drawing on reverse side. Signed " . ''Ti Date: FOR DEPART NT-USE ONL•Y,.--. - ....:� Application Accepted by ` .Data'- ` - e� > Area; Pit or Grout inspection by Date Final Inspection by _ Dat Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE t j INFO AMOUNT DUE AMOUNT REMITTED CASIt H RECEIVED BY 44 DATE PERMIT'NO. + EH13-24(REV.1 i w sf 1 EH 14-26 d 2