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APPLICATION FOR PERMIT SAN J'OAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 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 vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 'Z -�Z •� r'I t'1 k'- 9-Fes' ,City r a✓) Lot 81ze/Acreage e4 © r Owner's Name M 'e►'j+ n O 1:14�_Address a {� n 1r ��hone _� 9-3 f Contractor r Address z5z 7 l rf� £R License No.� Phone!EW-3 0Z TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION D Out of Service Well PUMP INSTALLATION E] SYSTEM REPAIR C OTHER C Monitoring Well U 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 -1 Industrial O Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private 0 Gravel Pack D Tracy Type of Casing_ Specifications 1'1 Public I-1 Other 11 Delta Depth of Grout Seal Type of Grout I i Irrigation _ Approx. Depth I I Eastern Surface Seal Installed by UP Repair Work Done L Type of Pump H.P. State Work Done_ Well Destruction O Well Diameter Sealing Material i Depth Depth Filler Material L Depth TYPE Of SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION ! 'DESTRUCTION I I (No septic system permitted if public sower is available within 200 feet.) Installation will serve: Residence_ Commercial_. Other Number of living units: Number of bedrooms / J Character of soil to a depth of 3 feet: 5 A-M 4--0 /-� Water table depth SEPTIC TANK [Type/Mfg C-0 0 C -C apacity M 0 6 4 ) No. Compartments Z PKG. TREATMENT PLT,0 If; Method of DisposRI Distance to nearest: Well Foundation f D 1M Property Line 1 0 0 f wQ-j'oolL e u T 01. 0 -r.+&I W_J Pyr f V% 04 rL Oo LEACHING LINE 0 No. & Length of lines _ Total length/size 16 O-O r FILTER BED CI Distance to nearest: Well Foundation Property Linev C vP 2 SEEPAGE PITS 11 Depth Size �_. Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS D 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 shell 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 t II for required in tions. Complete drawing on reverse side. Signed Title: Date: / FOR DEPARTMENT USE ONLY (y Application Accepted by Data fs Area 1 (, Pit or Grout Inspectlon by Date Final Inspection by Date b a Addhionaf 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 FEEI INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO, EH 1124(REV.iina) (� EH 14.26