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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 0 BOX 2009, STOCKTON, CA 95201 �; PERMIT EXPIRES 1 YEAR F90M_DATE ISSUED (Complete in Triplicate) Application is hereby made to Sari 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`51+9 and 1862 and the Rules and"Regulations of San �`- - Joaquin County Public Healthvices. Job Address v I lo Cit Lot Size/Acreage Jr~ Owner's " me Phone �Z v Contras r J" Address License N �3�4 Z_ `PhoYne� - - TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION/!k, SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL FLD. _ PROP. LINE FOUNDATION AGRICULTURE WELL_ , OTHER WELL PITS/SUMPS _ INTENDED USE TYP F WELL PROBLEM AREA CONSTRUCTION SPE IFICATIONS 'C7 Industrial pen Bottom ❑ Manteca Dia. of Weil Exc i Dia. of Well Casing "' y 17 Domestic/Private 0 Grave! Pack C7 Tracy Type of Casing G Specifications I'I Public 17 Other CTI Delta.- Depth of Grout Seal Type of Grout irrigation .. .Approx. D"�I I astern (� Surface Seal Installed by Repair Work Done�❑ Type of Pump �,� H.P. DAl" I <- State Work one WeII�Destruction ID Well Diameterin I ' _ Sealing Material & Depth G r1 Depth Filler Material & Depth TYPE OF SEPTIC WORK:" 'NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is available'within 200 feet.) installation will serve: Residence— Commercial_ Other _ Number of living units: Number of bedrooms t Character of-soil to a depth of 3lest: Water table depth SEPTIC TANK: ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE L� No. & Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well, � Foundation . Property Line DISPOSAL PONDS ❑ f r 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 L` Home owner or licensed agent's signature certifies the following: "I"cartify that in the performance of the work for which this permit is issued, I shall-nots L employ any person in such manner as to become suNect to workman's compensation laws of California."Contractor's hiring or sub-contracting"signature` certifies th ollowing: "I certify that in the pertorman'a of the work for.which this parmit.is issued,.l shall employ parsons subject to workman's compensa- rion laws f "alifornia." The applic nt must call r 11 r wired spa ions. mplete drawing on verse side. Signed Title: �1' Y�l/�/ _ _ Dat •" OR EPARTMENT USE ONLY Application Accepted by Date Area iInspection by ate Final Inspection by 7rte-, 1 -!. Date Pit or IG o Additional Comments" / k Applicant - Return all copies to: San Joaquin County Public Health Services, Environments]. Health Permit/Services - 1601 E. Hazelton Ave., P 0 Box 2009,�Stockton, CA 95201 FEE I INFO UN7 DUE j' AMOUNT REMIT-TED CK 11 CASH RECEIVED BY DATE- PERMIT"NO, EH 13-24 PIEV.i i n sl ` EH 14.2e .. lQ /-ID^ r