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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 J P O BOX 2009, STOCKTON, CA 95241. PEMIX EXPIRES 1 YEAR FROM DAIE ISSUED �� (Complete in Triplicate) (� k Application is hereby made to San Joaquin Count for permit to construct and/or install the work�erein described. This PP Y q Y p / 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. / v Job Address &)I�ir<�4 A/ City `Sr0Ck-7/dNr Lot Size/Acreage "� l �1 X 77 _ Kwner's Name +' ` —__ Address -7 D&1AJ` f(f Phone Contractor ZOZJAJU Address IV .�49 .J 4 411o&:�/ � icense No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 11 DESTRUCTION ❑ 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 PITS/SUMPS — INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 17 Domestic/Private 0 Gravel Pack D Tracy Type of Casing Specifications C1 Public is Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation _._ Approx. Depth I I Eastern Surface Soul Installed by Repair Work Done LJ Type of Pump H.P. State Work Done T t, Well Destruction ❑ Welt Diameter Sealing Material & Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION (No'septic system permitted if public sewer is vailable within 200 feet.) Installation will serve: Residence— Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No, Compartments PKG. TREATMENT PLT, ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of fines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size _ Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant st call f all required insPections. Complete drawing on reverse side. �r q Signed X Title: ._ �J� _ Date: R DEf�ARTMENT USE ONLY Application Accepted by _ - - Date `` t` Area f Pit or Grout Inspection by Date Final Inspection by Data 61.1 Additional Comments: Applicant — Return sll copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK flECEIVED BY DATE PERMWNO. + EH 13-242IR✓:V.1ns) af��( e3 S ( `'/� LS