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_ APPLICATION FOR PERMIT SAN JOAQUIN 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 in hereby made to San Joaquin County for a permit to construct and/or inatall the work herein described. This application is made in compliance vith San Joaquin County Ordinance No. 549 and x1862 and the Rules and Regulations of San _Joaquin County Public Health Services.�JA�` �' /91-11 _ Job Address Lop, �� k- ^^^ CiIy42 Lot Size/Acreage Owner's Name �s/ f��A Q Address Phone C� Contractor ,,��Address _ License No. �6- Phon �e / _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 ❑Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing O Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Rrbllc ❑ Other ❑ Delta Depth of Grout Seal Type of Grout — I I Irrigation _Approx. Depth 1 I Eastern Surface Seal Installed by Q Repair Work Done ❑ Type of Pump H.P_ State Work Done _ Well Destruction ❑ Well Diameter Sealing Material l Depth q Depth Filler Material a Depth V TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION IU/DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) r Installation will serve: Residence v Commercial_ Other Number of living units: I Numbergi bedrooms / Character of soil to a depth of 3 feet: Water table depth _SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal 5 Distance to nearest: Well Foundation Property Line ,{ LEACHING LINE 0-�No. & Length of lines � � Total length/size—S- ength/size S- FILTER BED Cl Distance to nearest: Well J--(G--fL� Foundation.,U/ Property Line C2�� f .SEEPAGE PITS W Depth a2d- -- ,Size- I t' �,,�jNumber SUMPS LI Distance to nearest: Well U/ Foundation ZFD/ Property'LineQD t DISPOSAL PONDS O 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 'hulas and regulations of the San Joaquin County Home owner or licensed agentis.signature_cenifies 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 candies the following:'9 certify that in the performance of the work for which this permit is igFufld,_I shall employ persons subject to workman's compensa- .Jion laws of California." , Theo call for all r uir inspections:Complete drawing on verse side. �f Signed��_�u a Title: Data: FOR DEPARTMENT USE ONLY / application Accepted by Daro - �� Area / 2 or Grout Inspection by Date/Final Inspection by Additional Comments: Applicant - Return all copies to: Ban Joaquin County Public Health _ Services, Environmental Health Permit/Services 1601 E. Razelton Ave., P 0 Box 2009. Stockton, CA 95201 IFEE NFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMITNO. fQQe latv.,,.ar fly-°° ILA-00 rnf� I