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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 BOX 2009, STOCBTON, CA 95201 R4&1 ku PERMIT 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 vlth San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County PubllcyHealth 9e1�7�ices. P�ru1, n M2 1 cess.�S al� 50 0 Cif-�Sma n oc'c' 6 City �r Lot Size/Acreage Job Address Owner's Name \)o Q_s :�- Ctx-V�- Address ( s (-h f SM O Phone Z- s.3 Conlractor��l ��'��"'�"f""`t�jO-P Address Z7° '�1 �C S-� S�+-�'�- License No. zS3 -3L6 Phone�"I "7 Z` TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Ll DESTRUCTION ❑ out 7service well Monitoring Nell LI PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11 n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation I o Dia. of Well Casing Type of Casing `"t t '�J C- Specifications C7 Domestic/Private al Gravel Peck T I Tracy g -2R_ c„tZ�ti r...0 Type of Grout fir'2�,,Z' I"I Public ❑ Other fl Delta Depth of Grout Seal y VP Approx. Depth I I Eastern Surface Seal Installed by�`" Q,�fzZ-LtL I I Irrigation P. Repair Work Done L3 Type of Pump N"`-.'- H.P. State Work Done_ Well Destruction ❑ Well Diameter , - " U, Sealing Material i Depth Depth Filler Material i Depth T PE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (Nailabptic cyst m rented if public sewer is Installation some: Residence_ Commercial_ Other Number of living an • Number of bedrooms Character of soli to a depth o et: star table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: We Foundation Property Line LEACHING LINE ❑ No. & Lengt ,nes Total length/size FILTER BED ❑ Dist to nearest: Welt Foundation Property Line SEEPAGE PITS I I Depth _Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DIS SAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, at ws, 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 must call for all required inspections. Complete drawing on reverse side. Signed CLo�0.vw - l a- a IP y ' r 1— Date: k ��-0..'� Title: 1' ,- '�_,A DEP IGIENT USE ONLY /7 Application Accepted by Date v Ars -7 Pit or Grout Inspection by Date Final Inspection by Date / ,/O- Q Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Razelton Ave.. P 0 Box 2009, Stockton, CA 95201 IN EE AMOUNT DUE AMOUNT REMITTED 7CASHFR=110EIVED BV DATE PERMIT NO.NFOEH 1324(REV.1/x e, 3$, 0� 35, •oo -5 -q � - -7 EH 14-28