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**W- APPLICATION FOR PERMIT --,., SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ,J ENVIRONMENTAL HEALTH DIVISION ? P 3 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOR 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 QOrdinance ✓No. , 549 and 186 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address ,T— City 1%— Lot Size/Acreage Owner's Name Phone Contractor 2 less ' 6 cense No. Phone a TYPE OF WELL/PUMP: NEW WErL ❑ WELL REPLACEMENT ❑ I DESTRUCTION ofoyt of ervice 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 D Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing N Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public 11 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U 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 I REPAIR/ADDITION I I DESTRUCTION 11 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: .1 Number of bedrooms _ Character of soil to a depth of 3 feet: � Water table de�th. 7 SEPTIC TANK ❑ Type/Mfg _ ___L`�' Capacity No. Compartments PKG. TREATMENT PLT. ❑ g n Method of Disposal Distance to nearest: Well (' 71 Foundation1r, 04 Property Line LEACHING LINE ❑ No. & Length of lines Total length/size Ain FILTER BED 0 Distance to nearest: Well l-� t'7 Foundation Property Linerte/ -4= .- SEEPAGE PITS 11 Depth C i:e Number UMP LI Distance to nearest: Well Foundation Property Line ISPOSAL PONDS ❑ I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and r 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 applicant ust all for all requi a spections. Comple a drawing on verse side. Signed X V�l1 �_� J� A Title: Date: / / FOR DEPARTMENT USE ONLY sem/ Ap cation Accepted by f f Date ` G Area ,Pit or Grob ction by Datef '� G Final Inspection by Additional Comments: — Applicant - Return all copies to: San Joaquin County Public Health �+ Services, Eavironmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT`REMITTED CK CASH/9`/ RECEIVED BY DATE 9 PERMIT NO. EH A-N IREV.rin51 ,/7� 1 L o ' J //-��/� ��.�W/ EH;I 2e v