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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES i V ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O 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 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 f Public 'C-'-` {-c,Health Services. (/ Job Address T / •� (�' ` -- City �ot Size/Acreage i Z Owner's Name tl z 44 ( Adtlress � 'z Phone J Contractor ddress se NoI� - Phone C _TYPE OF WELL PU NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION D Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing * Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications — I'[ Public ❑ Other fT Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. . State Work Done_ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material pth TYPE OF SEPTIC WORN: NEW INSTALLATION I I REPAIRiADOfTION DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial _ Other > CT Number of living units: _ Number of bedroom�_ Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity;�.419 No. Compartments PKG. TREATMENT PLT. LI I Method of Dis osal 1/ Property y _ z Distance to nearest: Wel Foundation Pro art line 1,12 LEACHING LINE ❑ No. & Length of lines o�__ ._.— Total length/size T FILTER SED ❑ Distance to nearest: ell $__ Foundation r Property Line Vn SEEPAGE PITS 11 Depth O Size Number. SUMPS LI Distance to nearest: Wel 1tS-Pf'±_ Foundation _� Property LineZ DISPOSAL PONDS Cl I hereby certify that I have prepared this application and that the work will be done in a_cordance 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 m at C30-Ijir all aqui ed i s ctions. Complet dt wing on reverse side. Signed% � Title: _MICAZ=�• �iy.- Date: R DEPARTMENT USE ONLY GQ _,�.. Application Accepted by C � �� _ �A,,:,.,,e�.,�..., Date - nn�' Area / 7� Pit or Grout Inspection by Date _�_ Fnal inspec!,w, by S�br/�/ Date Lr , � T Additional Comments: Applicant - Return all copies to: Sen J ,ayain County Publi< k;enite, Services, Environmental Heap^ ?ermiti Sergi/ices 1601 E. Hazelton Ave., P 0 Box 20,09Stockton, CA 95201 `A CK 4 INFO MOUNT DUE AMOUNT REMIrfEG i CA5t FEERECkfJtD BY GATE PERMITNO. {��^ EH 13]4(11 V11/X 5) /�J 1�� '—'� Ct/ti'•�� h 99 ) j �/ EH 4.7e