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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 , ! " SEP PERMIT EXPIRES 1 YEAR FROM DATE ED E)VV,R() 2 " �ti' (Complete in Triplicate) P� ]' IL Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein dec4� c�f'{{``..``�is /T application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations n Joaquin County Public Health Services. /} C (�Z l S~ /a* Q f S 74m �Gr" iCli"` 57 G� Job Address City Lot Size/Acreage Owner's Name 1V�J d r MAA.. Inc, Address P.o. Phone Z z Contractor sfYPto►k"'Address ?92-S_jff+ eyY'7q1* License No.big ZG8 Phone E: rpt TYPE OF WELL/PUMP: NEW WELL © WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Xl Monitoring Well C3 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE Ori1'1g S r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 5 �� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Q n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation (o Dia. of Well Casing Cl Domestic/Private Cl Gravel Pack 1) Tracy Type of Casing Specifications I') Public fa Other Fi Delta Depth of Grout Seal 364-411011 Type of Grout aftlaskilsad I i Irrigation qD Approx. Depth I I Eastern Surface Seal Installed by„T mr-",%e I Repair Work Dane U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I i INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line ;, LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number - SUMPS LI Distance to nearest: Well Foundation Property Line - DISPOSAL PONDS p r 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 ��II 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 L" 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 Cal' 'a." I The applic must all for all required itrspe 'on Complete drawing on reverse si L� Signed Title: Date: _2 FOR DEPARTMENT USE ONLY 1] Application Accepted by Date f , V Area Pit or Grout inspection by - Date Final Inspection by ✓rte Date/ 9U Additional Comments: Applicant - Return all copies to: San pp op Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 1 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'N0. INFO + Eli 13-21(REV.lin sl q ` EN A-29 v O "' 150