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i 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 PERMIT EXPIRES 1- YEAR FROM DAT ED (Complete in Triplicate) I Application is hereby made to San.Joaquin County for a permit to construct and/or install the work herein described. This i application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San I Joaquin County Public Hee-a{lth Services. k _p�,� _` ZS� �? �£ �`LL CitY �52[C1 f-- Job Address y p Lot Size/Acreage ` Owner's Name = �L'.�,�_"_. "ttG 7 0rri, \Address �� L � Contrataor 4 �` Address --.License No. Phone TYPE OF WELL/PUMP: NEW WELL © WELL REPLACEMENT- ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM-REPAIR ❑ OTHER ❑ Monitoring Well O 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 Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 4 i i'I Public I:] Other n Delta Depth of Grout Seal Type of Grout. -- J I I Irrigation _..Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L7 Type of Pump H.P. .� State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler•Meterial-&`Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is f] n available within 200 feet.) Installation will serve: Residence Commercial Other - +Y f Number of living units: . Number of bedrooms _ " E Character of soil to a depth of 3 feet: (-ICX Water table depth i SEPTIC TANK. LK Type/Mtg „ iA,L/ f n pir r-c- Capacity . No. Compartments ` PKG. TREATMENT PLT. ❑ f ! Method of Disppsal Distance to nearest: Welt Foundation i� Property Line 60 LEACHING LINE No. & Length of linear r 1Total length/size FILTER BED ❑ Distance to nearest: ti Wdll. C�4D _ Foundation Property Line 1(3 SEEPAGE PITS 11 Depth ... -Size __.,�._ Number SUMPS 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:,l 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 taws 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." Y The applicant must call for all require inspections. Complete drawing on reverse side. Signed X Title, f Date: DEP/A ENT USE ONLY Application Accepted by - -Date. Are Fir Pit or Grout Inspection by Date f=inal Inspection b ate I Additional Comments: ' r Applicant - Return all copies to.: San Joaquin County Public Health Services, Environmental Health Permit/Services F• 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH _ RECEIVED BY DATE PERMIT NO. I / q n' 1;H 13.24 IREV.1/H 51 ✓ _ 1_N , EH 94.26_ - - - k s