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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 BOIL 2009, STOCKTON, CA 85203. RNWIT EXPIRES i YEARFR013d DA E (Complete in Triplicate) Application is hereby taade,to Sate Joaquin County for a permit to construct and/or inetali the rrgrk herein descrkbed. This application Is made in compliance with San Joaquin County Ordinance No. 5159 and 1$C2 and the Rules and in describe of San Joaquin County Public Health Services. Job Address//e 6 `'t., / L_L-1C �j 41 City i Iot Size/Acreage Owner's Name `�. Irv' �< t-it Address) x ir; C` Phone rr / Contractor. �" L�7 -Address License No/ 1. 2-3 Phone 4++' 9 1 TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT O DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION 0 SYSTEM REPAIR 0 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 P Industrial 0 Open Bottom � Manteca Dia. of Well Excavation Dia. of Well Casing r.7 Domestic/Private ❑ Gravel Pack n Tracy Type of Casing Specifications — I'] Public I-1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation ____Approx. De Ah I I Eastern Surface Seal Installed by Repair Work Done 2 Type of Pump ��= H.P. 'a -A• � State Work Done Wall Destruction 0 Well Diameter Sealing Material & Depth Depth Filler Material 3 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is U Installation will serve: Residence— Commercial— Other available within 200 feet,] Number of living units: Number of bedrooms Character of sofl to a depth of 3 feat: Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT,❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. 6 Length of lines Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size __ Number SUMPS Ll Distance to nearest: Well Foundation Pro DISPOSAL PONDS ❑ Party Line r'1 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, rules and regulations of the San Joaquin County state Paws, and 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 taws 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, t shall employ persons subject to workman's compansa- tion laws of California." The applicant st cs I for all required inspections. Complete drawing on verse side. Signed X �'��1.:� �,�.,i,� _ �J l" Is: 12 � l Date: � 61 FOR Q ARTMENT USE ONLY Application Accepted by , Date i Area Pit or Grout Inspection by Date Fins] Inspection by� Date d i Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Servicer 1601 E. Hazelton Ave.. F 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DuE AMOUNT REMITTED INFO ASH RECEIVED BY DATE PERMWNO. EH 13-94(REV,t r n 5)EH A-211 f // b�