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v APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOR 2009, STOCKTON, CA 95201 �Lf PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application 1s 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 18�62 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address / / �'S w �QQS L� A'� Al City (51r44�� Lot Siz /Acre 1500 Owner's Name RoPQR f 9r Le4e< Address SC� Phone a-.1 Contractor_( MHOS!} SO4 Address y12 .5rtn co-T_A21 License.No.6736-lL5/ .__ Phone- V 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 TY Of WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r 77 Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications- yy I� CI Public Other n Delta Depth of Grout Seal O Type of Grout E*g A q'q1 K •/ IIrrigation _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 i Depth Depth -- Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.l In rve: Residence T Commercial_ Other Number of living units: bei of bedrooms - Character of soil to a depth of 3 feet: Water table SEPTIC TANK ❑ Type/Mfg Capacity . ompartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to'nearest: Well F ton roper Line LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER HED - -ET Distance to t: - 'Well Foundation Property Line SEEPAGE PITS Depth - Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPO,S L 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 o/the San Joaquin County Home owner or licensed agent's signature canities 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 subcontracting 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 ust 1 for all required in ctions. Complete drawing on raver ids. Signed X r .� 4014"— Title: Date: FOR DEPARTMENT USE ONLY p Application Accepted by !%%w Date Ph orrout Inspection by Date �� Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009.. Stockton, CA 95201 RE INFO AMQOONpT/DDU '/A`MMOOUN�TREMITTED CASH RECEIVED Hy EH1 al DATE 4PERMIT NO.. 'J • EH i (REV.iinsl ✓'�a..�