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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 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 andhetules,and Regulations of San Joaquin County Public Health Services. ,1 /� ,/,' Job Address Lot i ze/Acreage 1#10 V1__ Owner's Name YYL t Address 3 2 /5 7 � �� P4: Phone Contractor. 't 1 ttk0Address \Y` , V-)G��(�� fJL(r4e License No. als 7�Phone b S �C> 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 C.l Domestic/Private Ll Gravel Pack ❑ Tracy Type of Casing— Specifications ('I Public 1-1 Other F1 Delta Depth of Grout }pal _ Type of Grout I I Irrigation ___ Approx. Depth I I Eastern Surface Seal Ihsialled by Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material b Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION. DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence `/ Commercial __ Qther Number of living units: _/ Number of be o ms � I Character of soil to a depth of 3 feet: i"1'1-1 Water table depth C t SEPTIC TANK ';S- Type/Mfg G r Capacity 6� No. Compartments PKG. TREATMENT PLT. ❑ C_T ( _ Method of Disposal Distance to nearest: Well _ )C Foundation Property line LEACHING LINE Ll No. & Length of lines Total length/size FILTER BED Ll Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth ___ Size _ Number SUMPS LI Distance to nearest: Well Foundation 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 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 applicantt call forlran equi d inspections. Complete drawing on reverse sid �0 Signed X \ ` ) A— Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by JjL a C[it�G Date -[ L Area )i Pit or Grout Inspection by Date Final Inspection by __.!,e 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 �1,��