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APPLICATION FOR PERM I T SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOR 2009, ST'OCKTON, CA 95201 r. �I }. ZERMIT ,EXPIRES 1 YEAR FROM DAJE ISSUED (Complete iu 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 1662 and the Rules and Regulations of San Joaquin County Public Health Services. oQ 4 L T6K) Job Address City wG Lot Size/Acreage —Owner's Name � Cis Address $00 . ,3"-�to-^4 Phone (Rica) `ES-3—ZQ2 tR C 19 0 Contractor L%)%Ast, Address 233. ' L�ttr bv�J icense No,�5�1919 Phon 6 f+ - 2 TYPE OF WELL/PUMP: NEW WELL .' . _ -e WELL REPLACEMENT ❑ DESTRUCTION Ci Out of Service We1I ❑ PUMP INSTALLATION 0 c. SYSTEM REPAIR 0 OTHER ❑ Monitoring Well R` t„zg14 ` DISTANCE 70 NEAREST: SEPTIC TANK SEWER LINES� DISPOSAL FLD. PROP. LINEE ..17 FOUNDATION AGRICULTURE WELL OTHER WELL - PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 171 Industrial ❑ Open sot tom ❑ Manteca Dia. of Well Excavation 12" 6o Cf J<bomestic/Private WGravel Palck OC Trac T pVG Dia. of Wions sing Tracy Type of Casing Specifications Py I'1 Public is Other l n Delta Depth of Grout Seal - Y#* Type of Grout ..+ I i Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by tJte54' Repair Work Done L7 Type of Pump H.P. State Work Done _ J Well Destruction ❑ Well Diameter Sealing Material i Depth V Depth I Filler Material Ir Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION i 1.(No septic system permitted if public sewer is available within 200 feat.) 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, O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ I Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line I SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i I hereby certify that I have prepared this'application and that the work will be done in accordance with San Joaquin county ordinances, state lawsand i rules and regulations of the San Joaquin County , 11 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 i 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 ampioy persons subject to workman's compensa- tion laws of California." I. The applicant must call for all required i1m.ctions. Complete drawing on reverse side. Signed Tide: cz, (�•e,l-w1� �.i�¢��r-�l-J�¢g'�¢r`►.,.w...r� Dace: FOR DEPARTMENT USE ONLY Cj Application Accepted by Date ld ! [ Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: k L, Applicant - Return all copies to: San Joaquin oaquin County Public Health �� t7t1 i Services, &vironmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK I INFO CASH RECEIVED BY DATE PERMIT'NO. EH 3-24 C� �o Po 733i `�e_ IF