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APPLICATION FOR PERMIT a SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 EXPIRES-1 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 San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address f 3 r Z2 � - 1� , eD 1 rot- City l U&_� Lot Size/Acreage /� Owner's Name E'- 1 Jf�t[ Address 3 f 3C� E•-F© Phone l 3 ,' 7'75 Contractor ss Address A License Na. 3b Z Phone 7`/S--16 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION C) Out of Service Well ❑ PUMP INSTALLATION Ml--' SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ 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 n�ndustrial Open Bottom 11 Manteca Manteca Dia. of Well Excion -rr Dia. of Well Casing ill Domestic/Private ❑ Gravel Pack Ll Tracy Type of Casing Specifications I'l Public la Other fl Delta Depth of Grout Seal Type of Grout Ce MCA+ i I irrigation -=Approx. Depptth,, �I,I Eastern Surface Seal Installed by Repair Work Done L3 Type of Pump H.P. 3 State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth DepthFiller Material & Depth � t' er TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I lNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial T 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 V PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line A 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 lIshallt 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, Iemploy any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting 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 applicant must call for all r quired inspections. Complete drawing on r ve1se side. Q Signed X e l = Title: ! Date: " ✓ N— OR JAI ~ �D OR EPARTMENT USE ONLY Application Accepted by I. Date [. Area Pit orra Inspection by ate Fine) Inspection by Date Additional Comments: ` Applicant - Return all copies to: San J quin County Public Health Services, Environmental Health Permit/Servic s 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 INFE AMOUNT DUE M UNT REMITTED CASH RECEIVED BY DATE P/E�,RMIT N0, EK 13.24(REV.r/n.l ~2 EH -� 3 0_0 3�.�� 05 K- a v-x« P