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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 In hereby mode to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in comVIisace, with San Joaquin County Ordinance Ho. 549 and 1862 and the Rules and Regulations of San Joaquin County CP}ublic Health Services. ,/ �/[�. Job Address ` 39/7, ! �Gd4 �1��T -`� City Vol, �y Lot Size/Acreage SAC Owner's Name��Y �� 1 Address Phone Conlractor je frw r.0/ls2rs Address a 13,OY License Naw7731*S' Phone 3P` 4�� TYPE OF WELL/PUMP: _ NEWWELLX WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION' SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES t. DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELD t BOTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS -- ----" O Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation. Dia. of Well Casing -;J�omesiic/Private I�Gravel Pack ❑ Tracy Type of Casing Specifications f_-yPs Cl Public (Cl Other ' fl Delta Depth of Grout Seal /BC7�. • '17r'Type of Grout C«GNf I I Irrigation 1_%q Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done LlyTylx of Pump ys�-qH.P. 2 State Work Done'— Well Destruction ❑ iWell Diameter Sealing Material i Depth `Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION II'.l.i No septic system peimitted if public sewer iy 1 available within 200 feet.I Installation will serve: Residence? Commercial — Other • �' � r / ';� Number of living unite: Number of bedrooms Water table depth P ` Character of wit to a depth of 3 feet 1 l ' SEPTIC TANK- ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ f Method of Disposal Distance to nearest: Well Foundation Property Line ` LEACHING LINE O No. i Length of linesTotal length/size FILTER BED CI Distance to nearest: Well ` �. Foundation Property Line SEEPAGE PITS Id Depth I Size Number SUMPS CI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ - I hereby certify that I hive 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 licansed agent's signature cenifies the following: "1 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 applicant mu/sI IlIl ff r all rr tared inspections. Complete drawing on reverse side. L Signed X Title: f?'fNA..= Date: i F DEPARTMENT USE ONLY ' , Application Accepted by. 9hA v� Date a��qA Area A— Pit or ro Impecfion`by �• Date, ` Ftinal Inspection by ? ! f/'�Yf®/�, ✓� nate A Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Reaelton Ave., P 0 Box 2009, Stockton, CA 95201 �C�TVC INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. . EM 13 24 IREV.Heel 2(t t1.�(�I (� F� •� ..[) q 3 EM 14 2e ►37.� V 1:Y ll 1�S t� 17 d lam- /I 4