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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 O BOX 2009, STOCKTON, CA 95201 RERMIT EXPIRES 1 YEAR FROM DATE ISSUEDi (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 San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. I i Job Address et eCreek /�yy��o4 Ci,y r Lealotl Lot Size/Acreage Owner's Name ►C r ��(,�SQ,�, Address t 'Z 13 La s T .-y Q. (rl2lf Phone a 3 3 ( I Contractor ddre�s K License fVa. Phone X� " ? i TYPE OF WELL/PUMP: NEW WELL EA WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION lf- SYSTEM REPAIR 0 OTHER ❑ Monitoring Well L7 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_ F industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation U Dia. of Well Casing Domestic/Private IF Gravel Pack ❑ Tracy Type of Casing f Specifications I'I Public El Other f n Delta Depth of Grout Seal Type of Grout 930, I 1 Ifrigation _..Approxi Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump s uhW! H.P, -� State Work Done_ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE: OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ 4'Other Number of living 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. ❑ f Method of Disposal i Distance to nearest: Well Foundation Property Line LEACHING LINE CI No. & Length of lines Total length/size FILTER BED E=1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number Y 1 SUMPS Ul Distance to nearest: Well Foundation Property Line +1 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: "I 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(tiring 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 Califs The applican st call for all required inspe.cli omplete dra 'ng on vnerse side. Signed X Title: � ; (� Date: FOR DEPARTMENT USE ONLY I Application Accepted by aLl A KDate u� Area l' Pit or Grout inspection by Dae Final Inspection by �' -S� r1 Date Additional Comments-. Applicant - Return all copies to: $sut Joaquin County Public Health , Services, Environmental Health Permit/Services i 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERM17 tJO. I . EEH Q 24H 13.24IAEV.iiM5) 0 0 ! 1 r v n