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f APPL I`CAT I GN FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95241 PERMIT EXPIRES 1 YEAR FRQX DATE ISSUED (Complete in Triplicate) Application is hereby made to Sen 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 Joaquln,County Public Health Services. _ Job Address City G D /, Lot Size/Acreage Owner's Name to /111�+r �J 1— Z1//1 Address Phone !d Contractor / Address _ .= Aloe J;ilf7tl License No._6_ Phone TYPE OF WELOPUMP: NEW WELL ❑ WELL REPLACEMENT M DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION [ice SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD. PROP. LINE FOUNGAT:ON - - AGRICULTURE WELL _ -OTHER WELL--_ _,._ PITS/SUMPS- Y INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F1 Industrial ❑ Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing N Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'] Public [:1 Other n Delta Depth of Grout Seal Type of Grout I I Irritation _,, Approx. Dep�h I I Eastern Surface Seal Installed by Repair Work Done L7 Type of Pump ? G H.P. State Work Done — Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Materiel & Depth TYPE OI: SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I i INo septic system permitted it 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 i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line _ s LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED C1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI 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 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 applicant cast f all r qui d i psctions. Complete drawing on reverse side. Signed X Title: Z2Date: v '? R DEPARTMENT USE KY q Application Accepted by ✓ Date * Area Pit or Grout Inspection by Data Final Inspection by Date-Z_.A/ Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Eavironmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 1NFO FEE AMOUNT DUE AMOUNT REMITTED I CASH RECEIVED BY DATE PERMIT NO. F H r CHI 3.24(REV.1/n sl ry�< I I V i� L�• ! .�f Q } I f /� EH 11,26