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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 BRUIT 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 Health Services. Job Address �/ �!v GAr�� City Lot Size/Acreage Owner's Named �' Address Phone -043 J i f Contractor �lSurd� l -F` 'gC;_ Address r -I3drs License No.^r'Aetylo Phone.X 9- qz,-?e TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION D Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O 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 C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing CI Domestic/Private ❑ Gravel Pack Q Tracy Type of Casing Specifications Cl Public Cl Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation ..,_._.Approx, Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material d Depth TYPE OF SEPTIC WORK: NEW INSTALLATION Or REPAIRlADOITION I I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.1 Installation will serve: kesidence Commercial l Other Number of living units: Number of bedrooms Character of soil to a.depth of 3 feet: Water table depth SEPTIC TANK. Type/Mfg - Lam_ C-6 p'CK-£Z _ Capacitym�ea- _ No. Compartments PKG. TREATMENT PLT, ❑ Method of Disposal r Distance to nearest: Well r©p Foundation /o� Property Line . /a' LEACHING LINE No. f& Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation w Property Line /a SEEPAGE PITS llDepth Size Number SUMPS Ll Distance to nearest: - Well Foundation Property Line DISPOSAL PONDS Cl `\ 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 rulesanis regulations of the San Joaquin County Horne 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 f` 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 must call for at required inspections. Complete drawing on reverse side. i Signed X Title: Date: F PARTMENT USE ONLY Application Accepted by C&Z44A Date Area Pit or Grout 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 FEE INFO AMOUNT.DUE AMOUNT REMITTED CASH RECEIVED BY DATES Q PERMII'NO. 00 EH 34.26