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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES CCS ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. . PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 EXPIRES 1 YEAR FROM DATE ISSUM (Complete in Triplicate) Application is hereby trade 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 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address Aix.M_ City Lot Size/Acreage "—i Owner's Name�^�� t l/_1L_f ff S �cOp(dresIJ Phone 3 31 Contractor ~} I(I W'A Address D,486'1,3( �� w 9./Y__License No.coq-3 r3 Phone ` i=2 7 29 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Out of Service well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER © Monitoring`Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE&_e AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 177 Industrial ❑ Open Bottom E3 Manteca Dia. of Well Excavation Dia. of Well Casing E:I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'I Public 1-1 Other n Delta Depth of Grout Seal Type of Grout 11 Irrigation ,r —Approx. Depth I i Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump _ H.P. –'-;rate Wook.Oo _ Well Destruction Well Diameter �._ , Sealing Material & Depth } /1 / ew h L� Depth Filler Material & DepthM Qi2 Q N� TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ( I DESTRUCTION I I Wo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ 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.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll 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 1 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 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 applliica�ntm�t call for all required diinspections, CorAplete drawing on reverse side. Signed �(�L�6f� /�� - Q9 Title: S_ -L/ /L�� _ Aata. C Z/e FOR DEPARTMENT USE ONLY �/7 Application Accepted by Date r Area`r f - Pit or Grout Inspection by Date Final Inspection b 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 FEEINFO /AMOUNT DDUUE1 AMOUNT REMITTED CASH RECEIVED BY DATE PERMI7'NO. Err13- (ACV.t ns EH it-25Zd