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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 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address L��n �^ C� 3�lf llf' i2� City(26d5L9Zf.C,rrL9t Size/Acreage /rJ f,7c_ /J za 9 Owner's Name 'w icy - 119CX COL'. Address L>n doY 6n 90 L' fmE� i Phone G qs«7 ContractorAddress_��.> -.F License No. Phone 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 PtTS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C.1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Il Public fl Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth 11 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 1 I DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Ic—" Commercial_ Other Number of living units: �� Number of-bedrooms _ Character of Will to a depth of 3 feet: Zap C t'K.9 K Water table depth r� SEPTIC TANK ❑ Type/Mfg au. rapacity 121%11 No. - - Compartments �. PKG. TREATMENT PLT. ❑ �.T Method of Disposal Distance to nearest: Well Foundation —'Z-C1 rT Property Line e!!? FT LEACHING LINE Nk No. 6 Length of lines 2. Total length/size FILTER BED ❑ Distance to nearest: Well Foundation S`% Property Line. � SEEPAGE PITS I)( Depth 2 S Size Nkmber SUMPS LI Distance to nearest: Well KV Foundation 9.0_ Property Line d DISPOSAL PONDS ❑ 1 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 n t 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: "1 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 for all required nspgcti a. Com ate drawing on reverse side. Signed X �[ i .�� _ Title: 4:�4 1 - do�F_ Date: n<1 ' O EPARTMENT USE ONLY 11 Application Accepted by Data "� Area I _ P8 or Grout Inspection by ate �C Final Inspection by 1� 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 INFO AMOUNT DUE AUNT REMITTED CASH CK 0 RECEIVED BY DATE PERMIT'��N---01st. EH 13-24 IREV.,ix sl t EH 1 624 t Y