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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 5 ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 M—RUST__EXPURES 1 YEAR FROM DATE ISSUED } (Complete in Triplicate) Application ie 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. f f� Job Address :S,2a �/��a i�C� City Lot Size/Acreage - i---- Owner's Name ___ 4 "(Y V �1 !,�.5 Address Phone-a { Contractor I`, 1 ��n Address, License N,r� d , O�: ]E3 Phone TYPE OF WELL/PUMP:; NEQV EL: 1 WELL REPLACEMENT DESTRUCTION ❑ Out of Service Well ❑ �� PUMP INSTALLATION r SYSTEM REPAIR 0 OTHER p Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK 0� SEWER LINES r DISPOSAL FLD._� PROP. LINE~S0- r �° 71: FOUNDATION .AGRICULTURE WELL OTHER WELL PITS/SUMPS`ir9 [J INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECiFICATIQtJS Cl Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing�! Domestic/Private 1 ❑ Gravel Pack ❑ Tracy Type of Casing a e_ Specifications I'1 Public ss-1-1� 1 Other - — • � f"1 Delta Depth of Grout Seal � Type,o r.row I i Irrigation 3C Approx. Dept I 1 stern f6 ace Seal Installed by_I n ` j��r Repair Work Done U I Type of Pump H.P. � _� ` State Work Done _ Weil Destruction ❑ Well Diameter Sealing Material & Depth i Depth Filler Material IG Depth (r TYPE OF SEPTIC WORK k NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is t available within 200 lost.) Installation will serve: Residence_ Commercial_ Other Number of.living units:.. Number of bedrooms Character of soil to a dt3pth of 3 feet: Water table depth SEPTIC TANK. w❑ Type/Mfg °_ _ _- Capacity No. Compartments PKG. TREATMENT PLT.ggq❑ 1} Method of Disposal r �. Distance to nearest: Well Foundation Property Line LEACHING`LINE �❑ t.No. & Lerigth of lines J Total length/size FILTER BED �❑. Distance to nearest: Well Foundation - Property Line SEEPAGE PITS ,�I I Depth Sire _ Number SUMPS 'Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS _ tet❑ I hereby cartify 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 laws of California." Contractors(tiring or subcontracting 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 applicant must call for all required inspections. Complete drawing on rever:2� Signedr. Title: __ � ��TS _ Date: ,Aq FOR DEPARTMENT USE ONLY � zApplication Accepted by. Data Area q� Pit or Gr ! Inspection by f Date Final Inspection by G Dots Additional Comments: 11 Ll — Return al!1. copies to: San Joaquin County Public Health I Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK A CASH RECEIVED BY DATE PERMIT*NO. . EK 13-24(REV.11AS) 1 ID9 qT f7�a EH 14.26