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APPLICATIONIFOR PERMIT SAN `JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION � 1601 E. HAZELTON AVE. , PHONE (209)46$ gCHADO —3420 2M N.JacktRoad P O BOR 2009, STOCRTON, CA 95201 Stockton, Csllfomla 95215 -PERMIT EXPIRES ]L YEAR FROM DATE ISSjJED (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 cotapliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address Z&6 City_ Lot Size/Acreage i Owner's Name ftA2 A Address 56. �" 'e Phone / Contractor _LZYZTAddressr,L� - C74 tp License Noa2,/C/7d Phone/� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT.❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR` OTHER ❑ Monitoring Well �} DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing VDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public Cl Other f-I Delta Depth`of Grout Seal Type of Grout I I Irrigation w.Approx. Depth 1 I Eastern Surface Seal Installed by Repair Work Done � Type of Pump H.P. _� State Work Done a a�— Well Destruction ❑ Well Diameter Sealing Material & Depth -- Depth Filler Materiel & Depth d . TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAtR/ADDITION I i DESTRUCTION I. I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence. Commercial_ other _Number-of fixing_units:_ __Number of bedrooms _ Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. C1 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line CZ LEACHING LINE D No. & Length of lines Total leh'gth/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 ❑ 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: "l 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 ea scant t cati for all requ' inspec ' ns. Co late drawing on reverse side. Si ned -� Title: Dat®: 9 i OR DEPARTMENT USE ONLY Application Accepted by _ �&QAA- ,�, gA,Q of i,.,� Date _ Area Pit or Grout lnspection by Data Final Inspection by Date l Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., F 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CCK REECEIVVED BY (��t DATE PPE7RW NO. a EH 13-24(HEY.1/K 51 �� V W.--✓ ! 40 EH 14-2e ✓ ,{