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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 O 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 with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. I. Job Address ' : �X / /' 4- -�1' A/'1 + City ` Lot Size/Acreage 60 Owner's Name .�{`L CSL ��— Addressf l�'` � �.V''''esf Phone a. Contract 11.A4�-</f f Address(• ` 7,1 % t�`.17%�-�! License No. "� 7�� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ r 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 _ r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing n Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 5 I'I Public 1:1 Other 11 Delta Depth of Grout Seal Type of Grout raw I I Irrigation _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 & Depth ` Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 I REPAIR/ADDITION X DESTRUCTION I I (No septic system permitted if public sewer is .� available within 200 feet.) Installation will serve: Residence-L' /. Commercial_ Other Number of living units: -C-- Number o/ ooms r / Character of coil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity / :l/ No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size r_ FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth ,25- Sizet��• umber �� r r SUMPS LI Distance to nearest: Wall 1AFoundation 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: "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 must c for all req�wfed inspections. Complete drawing on reverse side Signed X Title: L + Date: 1 FO�.R� D�EP�P/�iTMENT USE ONLY Application Accepted by S Area q it Grout Inspection by r ate Final Inspection by -��if 7dacr,.�//late }- 9i r Additional Comments: Applicant - Return all copies to: San Joequin County Public Health `��Services, Environmental Health Permit/Services fz `1V1� 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201FEE �- INFO AMOUNT DUE AMOUNT REMITTED CAS, RECEIVED BY DATE PERMIT'NO. �' EEM N AmIREV.r,rt sr5 ll` C,-,