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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES x ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOR 2009, STOCKTON, CA 95201 P .. IT MXRES ] 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 application is made in compliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. f Job Address 1 C eb G City v Lot Size/Acreage Owner's Name ' s.,__'----C�-X-1--_---- ---_- Address. Phone � f 0 Contractor.i. - AddressA e0y 17, License No3773� t Phone I TYPE OF WELL/PUMP: NEW WELLA WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service Nell (Y PUMP WSTALLATIONMJ SYSTEM REPAIR ❑ e OTHER C).1 Monitoring well �� y DISTANCE TO NEAREST: SEPTIC TANK _/J? SEWER LINES DISPOSAL FLD.I L2 PRQP, 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 Domestic/Private Gravel Pack ❑ Tracy Typo of Casing IVyc Specific6tio6 I'I Public I:1 Other f-1 Delta Depth of Grout Seat Type of Grout. ft.,I,elvf 1 1 irrigation 3 03� Approx. Depth I 1 Eastern Surface Seal Installed by a1 Repair Work Done 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-Sys lern pertnined it public slower is avaitakrle within 200 lout.)- Installation will serve: Residence.• Commercial_ Other Number of.tiving 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. 0 Method of Disposal Distance to nearest:.- Well Foundation Property Line .j k LEACHING LINE 0 . No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line - t SEEPAGE PITS I I Deptti, Size _ _ Number € SUMPS L1 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 cenifies 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 rnanner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons supject to workman's componsa- tion laws of California." The applicant must cat for all required inswlions. Complete drawing on reverse side. 4Signed Title' Datp: 3" �L 7- TMENT USE ONLY Application Accepted by Date Area — Pit or� ut Inspection by Date �I�Z 6 Final Inspection,.by late Additional Comments: Applicant - Return all copies to: San Joaquin'County Public Health Services, Environmental Health Permit/Services a 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA `95201 FEE AMOUNT DUE AMOUNT REMITTED R@CEIYED BY PATE PERMIT'NO. INFO CASH • EH 13.26 IREY.1 , 'Sl Ei 74•26 10S _0_0 -�r . qo Rf-" 4(P I Q f S