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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 BOR 2009, STOCKTON, CA 95201 EXP RES 1-,Y AR FR M DATE (Complete in Triplicate) I 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. 5119 and 1662 and the Rules and Regulations of San Joaquin County Public ]Health Services. r I l� 7 I Job Address !2 7 f i okd Co tam I City ��` Lot Size/Acreage C' / Owner's Name �7!Uem cq"'(o` o) Address 0®2 Z ,u herrn Stkl Ph `1.77"71 Contractor � � Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL L REPLACEMENT P_ DESTRUCTION ❑ Out of Service Well ❑ 1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 0 j 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 R Industrial ❑ Open Bottom D Manteca Dia. of Well Excavation, Dia. of Well Casing C1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public f:I Other n Delta Depth of Grout Seal Type of Grout I I Irrigation ____.Appfox, Depth f I Eastern Surface Seal Installed by ti Repair Work Done L] Type of Pump H.P. State Work Done n Well Destruction f3 Well Diameter Sealing Materiel & Depth Depth Piller Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADOITION f I DESTRUCTION I I INo septic system permitted it public sewer is available within 200 feet.1 Installation will serve: Residence Commercial_ Other ; Number of living units: —I— Number of 20,Fs Character of soil to a depth of 3 feet: �� Water table depth I SEPTIC TANK ❑ Type/Mfg 1' f C- - -- Capacity 2Q No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well 2 7S Foundation Z S Property Line LEACHING LINE D No. & Length of lines �,�2 Total length/size_ FILTER BED n Distance to nearest: Wall 20 Foundation _ 4'0 Property Line SEEPAGE PITS 11 Depth 2 Size r 33X Number 2- SUMPS LI Distance to nearest: well.. 3 b,9 Foundation Property Line f� - 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, a rules and regulations of the San Joaquin County ' Home owner or licensed agent's signature certifies the following: 1 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 . tion laws of California." The applicant m t call for all required inspections. Complete drawing on reverse side. Signed X � �� Title: 0,6. =NDate: 3 -30_ R DEPARTMENT USE ONLY Ap ication Accepted by Date 3,�"�� Area it Grout Inspection by Date 2(� Final Inspection b--re ��J Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Servicea 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEEMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERM17"N0, INFO CASH 0 EH 13-24 iREV.�/n 64 r(`� __7() 3!/ 31ytJ <?V EH 11.26