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C APPLICATION FOR PERMIT ` SAN JOAQUIN COUNTY- PUBLIC HEALTH SERVICES ENVIRONMENTAL, HEALTH DIVISION 1601 E. HAZELTON AVE, , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 MIT EXP RES 1 YEAR FROM DATE € (Complete in Triplicate) - Application is hereby stale to San Joaquin County for s permit to construct and/or install the work herein described. This application is made in compliance vith Sean Joaquin County Ordinance No., 5Lg and 18b2 and the Rules and Regulations o1 Sand Joaquin County Public Health Services. ' Job Address . � ` f - k G City Lot Size/Acreage` ' Owners Name . — - r - c _` _Address _ _ j _ Phone " Contractor._,A__L— K Address I t TYPE OF WELL/PUMP: eLicense No. Phone NEW WELL LJ REPLACEMENT [ ] Dof Service Well ❑ DESTRUCT( ❑ Out i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ :.: OTHER ❑ Monitoring Well [ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES LINE., 13 DISPOSAL FLD. PROP. FOUNDATION. '' AGRICULTURE WELL ` OTHER WELL PETS/SUMPS t INTENDED USE TYPE OF WELL` PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom `❑ Njan^rocs f } I A Dia. of Well Excavation t t f:� Domestic/Private U Gravel Pack D;a.(of Well Casing I L7 Tracy Type of Casing i € f'1 Public Cl Other { Y 1 Delta Specifications -r~ I Depth of Grout Seal i I I Irrigation —Approx. Depths„ I'! Eastern Type of Grout Repair Work Done ❑ T - 4 Surface Seal.lnsialled by. i Type of Pump H P State Work Done .:j Well Destruction ❑ �fWelt_DiameterV "" '` x Sealing Material & Depth 4 Depth Filler Material & Depth i e TYPE OF SEPTIC WORK; NEW INSTALLATION REPAIRlADOITION 1 i DESTAUCTfON 1 1 (No septic'system permitted it public sewai s f " /k available within 200 feet•) fnstaflaYron will serve: Residence v+ 't Commercial r�„- t # Other Number of living units: I NumbiL�� r of r Character of soil to a depth of 3 feet: , 11 f SEPTIC TANK. 6 Type/Mfg, f _ Water table depth T g PKG. TREATMENT PLT. Cl ac Capacity_ 4No, Compartments r � 1 + Alethod of D;sposal' r Distance to nearest: Wetl _ Foundation PropertyL'ine F LEACHING LINE I�No.'& Len�th of lines = FILTER BED El Distance to nearest: *Well _ f tel length/size -�Fiiund ion Pro party Line f SEEPAGE PITSI I' r } yDepth r SUMPS - 4 � �/ Nuf.bar (`pistance tonearest: 'r« - welt T a '. Di- DISPOSAL PONDS - Foundation_ a Property Line��'• ❑�- s ! hereby certify that I haveprepared this application.and that the work will be done in accordance with San Joaquin county ordinances, state la 1 rules and regulations of the San Joaquin Count w Home owner or licensed agent's signature certifi s the following: r_ t laws, and formance employ any person in such manner as to become subject,to work ms�n's compensatify that in on taws of Ca4ifo of Contractor's work for rhiringl mil is sued, Ishall not tjOn la the California,"o '9 certify that in the performance df-.the work:for which this permit is issued, I shall employ tion laws of Cfornia % signature y persons subject to work en's compensa- The applicant must ca for all re trod inspections. Complete drawing on reverse side, Signed ✓ i Date: 7 TMENT USE ONLY Application Accepted b Date Ar Pit or Grout Inspection by Date � ----�.,— Final.Inspection by Additional Comments: { 1 - , Applicant - Return all copies to: San J 1 ° oaquin County Public Health -- ---Services, Environment&1-Health--Permit/Se'rvices� 1601 E. Hazelton Ave., P 0 Box 2009, Stockton CA w.•, j �� r FEE 95201 INFO AMOUNT DUE I AMOUNT REMtTTEoe f CA$HI RECEIVEDBY_ r `3 DATEPERMIT'No. • Eli 13-24 4REV.I/n 51 EH 14.28