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i APPLICATION FOR PERMIT i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1.601 E. HAZELTON AVE. , PHONE (209)468-3420 � P 0 BOX 2009, STOCKTON, CA 95201 PXIX XP I REQS/1• YEAR FROM DATE IS„ VED (Calnplete W'TripIicate) Application is hereby made,to San 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. 449 and 1862 and the Rules and Regulations of San Joaquin County (Public Health Services. `, Job Address / 7_ T3 ��Y ` �_ CityLot Size/Acreage r '+'1 AddresshT;�C,----._....__ .....� Phone ' Owner's Name ,S Contractor _Address icense`No. 41S��a�Phone-? �' f TYPE OF WELL/PUMP: NEW WELL 171V.M1 WELL REP CEMENT ❑ DESTRUCTION 10 Out"of Service Well 0 PUMP INSTALLATION ❑ ! SYSTEM REPAIR C? r OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD_, _ „P,ROP.LINE FOUNDATION AGRICULTURE WELL`"` OT;NER WELL t PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA 11 CONSTRUCTION SPECIFICATIONS r_l Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation '" ""Dia:-of-Well-Casing' D Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specilicationt: Il Public 1-1 Other 171 Delta. Depth of Grout Seal Type ol_Grout i I ifrigalioo — Approx. Depth- I I Eastern ` ' Surface Seul-Insiiilled by Repair Work Done U Type of Pump H.P. State Work'Done _ Well Destruction ❑ Well Diameter Sealing Material &--Depth t- Depth -Filler Material &-Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITIONX DESTRUCTION I I (No septic system permitted if public sewer is } available within 200 feet.) ${ Installation wilt serve: Residence.. Commercial_ Other 1t Number of living units: Number of bedrooms W +t l Character of soil to a depth of 3 feet: Sf222& Water table depth i SEPTIC TANK.. ❑ Type/Mfg Capacity /f920`a No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal a Distance to nearest: Well le Foundation _ Property Line !, LEACHING LINE ❑ No. & Length of lines © Total length/size U' FILTER BED ❑ Distance to nearest: Well ..Z2# Foundation _fry Property Line /40. SEEPAGE PITS 11 Depth _Si:e._ Number \ , SUMPS LI Distance to nearest: Well1,gpa Foundation '! /V Property Line�_ ((( DISPOSAL PONDS 0 f 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-itissue2l, 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." - fi The applicant must c r all requi inspections. Complete drawing on reverse side. _Y I Signed Title: Date: sig .�d R DEPARTMENT USE ONLY , E Application Accepted by - :Date - - Area J - r or Grout Inspection by Date final Inspection by Date Additional Comments: t r Applicant = Return all copies to: San Joaquin County Public Health �. . . .... _, .. .,.....Services,-Eavironmental,Health-Permit/Servic'es-'`"""'"�"`""-'�"-� 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. } 70 EH 13-24 1REV.1'�H 51 Eli 11•�