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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTHNDIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 i ry PRUIT 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 i application is made in compliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of-San i Joaquin County Public Health Services. - f t o Y f�3 Job Address Q� y,�Q � City -� Lot Size/Acreage 3 S ' V tr . J' 71 A.h�C. Owner's Name ...pr Address �A- .. ..._._— Phone � -10 Contract o i Q� A LU Address .1,,.b,_.L,? ,.1 �� r^'�, License No.lis z Phone (.8 S .5 TYPE•OF.WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of ServiceTell ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER" ❑ Monitoring ell L7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. _ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS sr INTENDED USE TYPE OF'WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 171 Industrial ❑ Open Bottom C] Manteca Dia. of Well Excavation Dia. of Well Casing [I Domestic/Private ❑ Gravel Pack C1Tracy Type of Casing Specifications I'] Public S. I-) Other n Delta Depth of Grout Seal Type of Grout I I Irduation _Approx. Depth I I Eastern Surface Seal Installed by 1 Repair Work Done ❑ Type of Pump H.P. ' State Work Done _ Well Destruction ❑ Well Diameter Sealing Material-.&.Depth Depth 1-11er.Material & Depth TYPE OF SEPTIC WORK: NEW INSTAL-•. _ .AIR ADDITION DESTRUCTION € I Mo septic system permitted if`public sewer is Q f available within 200 feet,) Installation will serve: Residence�✓ `Commercial_ -Other ["ChaNumber of living units: J— Number of be ooms .3 _ ' ! (71- Character racter of soil to a depth of 3 feet: _ Water table depth t SEPTIC TANK ❑ Type/Mfg '" Capacity - No. Compartments PKG. TREATMENT PLT. ❑ A Method of Disposal Distance to nearest: Well- Foundation Property Line 1 LEACHING LINE ❑ No. & Length of lines M ;" Total length/sire r FILTER BED Cl Distance to nearest: Well Foundation A Property Line I SEEPAGE PITS Depth 5 Sixey —F - T 1Vumber SUMPS El Distance to nearest: Well Foundation ib Property Line - - DISPOSAL PONDS ❑ I hereby,Oeftify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules end 4`ulations of the San Joaquin County Home o%Wner 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 al,y 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 mu call for eq ed inspections. Complete drawing on Vq reverse i �. Signed Title: v, Date: t C FOR DEPARTMENT USE ONLY __- _ l ' tion Accepted by +7_1 _._ Date Area �^ Pi Grout Inspection b� G, �T� Da1e6_ 'C IG i k Final Inspection by� 1166CY--`• Date 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 97.AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE G I ERMI7'NO I � EH7CmIpEV.�in51 1y.0v r •� `� ✓L�~ J ' �r �r/ '