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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES M,Q4.4/ ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOR 2009, STOCKTON, CA 95201 s 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. Job Address [Y k ��i.il ��" A City i Lot Size/Acreage Owner's Name L c'1 u_ Ph I L A J Address �� 1,x 05- 6A Cr G-fl Phone 7 • S 3-:2Z Contractorc'l4S (.t1 t '�h Address . L'. f x �Li -LA License No. Phone -2 4c TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION O Out of Service Well O PUMP INSTALLATION T�?. SYSTEM REPAIR ❑ OTHER O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK 100� SEWER LINES 100) DISPOSAL FLD.1�7%0 PROP. LINE Jf FOUNDATION 7 L� AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing KDomestic/Private 0 Gravel Pack O Tracy Type of Casing_ SC Specifications 1 Z:5A. Il Public 1-1 Other fl Delta Depth of Grout Seal - L7 1 Type of Grout C/IiAe K LAI.:�� I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Lt/'A0 L i��/ f�•-jaj)rti�% Repair Work Done U Type of Pump Si/ 6 H.P. '- State Work Done_ Well Destruction O Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE D No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size _ Number SUMPS I-1 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 applicant must /c�all,for alll required ins ctions. Complete drawing own reverse side. "L r�t !� 1' inZ--I- Title: 1 , :J/11 /� Signed X �.-/ � i 1. Q l?_, Date: OR PARTMENT USE ONLY 7 Application Accepted by j - Date — Area x•--- Pit or t Inspection by y � 1� Date Final Inspection by � �Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health 1``�� Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 INFO AMOUNT ELL UE AMOUNT RFMITTED CCA K RECEIVED B`I DATE PERMIT NO.