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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-342 P 0 BOR 2009, STOCKTON, CA 95201 �� 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 abed. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules �R a of San Joaquin County Public Health Services. Job Address 40 00U4Jt1 4 7 City Lot Size/Acreage r� D l?'61a-�aW Owner's Name �`^ Address a2$�0��► iRtc�-� - X3100 Phone Contractor S �r't�>� —X ( 1�Address �Jr L. ►/ I License No.t+/C;6"(Py Phoneme `mss TYPE OF WELL/PUMP: NEW WELL V WELL REPLACEMENT ❑ DESTRUCTION Q Out of Service Well ❑ PUMP INSTALLATION SYSTEM�Rr ❑ 0TH R O MonitoringWellp� DISTANCE TO NEAREST: SEPTIC TANK _# SEWER LINES � DISPOSAL FL=C! 'ROP. LINE 40 / FOUNDATION — AGRICULTURE WELL*1m BOTHER WELL PITS/SUMPSs�7� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIOf p N Vindustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation // Dia. of Well Casing [] Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Pll tC� Specifications Il Public 1)(Other IyDelta Depth of Grout Seal —1Va,.L Type of Grout T By 1 1 Irrigation 6 S Approx. Depth I I Eastern Surface Seal Installed by _rQ 0 Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if 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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant ust Call fo all requireedd inspe. tons. Complete drawing on reverse/side. Signed Title: R DEPARTMENT USE ONLY Application Accepted by 1Date ` �-•� Q� Area 7 Pit or Grout Inspection byT oDateo42-7bz5 Final Inspection by Data 7 �� Additional Comments: Applicant — Return all copies toe San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Razelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASN RECEIVED BY DATE PERMIT'N0. . EM 13*24 IREV.1i85) C TT �� G� ✓/ �/�1� D O� EM 1440 �J VlJ �o /Ifw• i✓ v