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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 EXPIRES 1 YEAR FR M DATE ISSUED (Complete in Triplicate) Application•is hereby made.to San Joaquln'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 Cotzttty Public Health Services. Job Address ^��4 6,�E cityJ_ Lot Size/Acreage Owner's Name a mad � � !=Address Phone �i ' / �l�� f /vl License lVo��ci� 13� Phone Contractor T:2, ��C C�Address TYPE OF WELL/PUMP: NEW WELL ❑ -- .WE-LL-REPLACEMENT .❑._. _,_„--QESTRLICTJON_0 Out.of-"Service Wel'T"❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ NonitoringlWell [7 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 n Industrial CJ Open Bottom 171 Manteca Dia, of-Well Excavation ' Dia. of Well Casing C1 Domestic/Private F_l Gravel Pack L1 Tracy Type of Casing Specifications F1 Public C1 Other Fl Delta Depth of Grout Seal Type of Grout I I Irrigation ____.Approx. Depth l I Eastern Surface Seal Installed byt Repair Work Done 0 Type of Pump _ H.P, State Work Done T O Well Destruction ❑ Well Diameter Sealing Material & Depth [ 0 Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION ,i REPAIRIADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is �� available within 200 feet.l Installation will serve: Residence L._ Commercial_ Other r Number of living units: / Number of bedrooms f Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg i Capacity- ,� No. Compartments PKC. TREATMENTT. ❑ . ter-% a-�"1 ,PLMethod of Disposal ./,fie { Distance to nearest: Well Foundation -� ' Property Line/,J LEACHING LINE No. & Length of lines Total length/size 0 f� FILTER BED ❑ Distance to nearest: Well 1 Foundation �7 Property Line I SEEPAGE PITS 11 Depth Size Number SUMPS LI 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 call for all require ins ctions. Complete drawing on reverse side, Signed X Title: �7�C/ ' Date: %41 R DEP TMENT E ONLY Application Accepted by Date," A a Pit or Grout Inspection by Date Final Inspection byDate Additional Comments: Applicant - Return all copies to: Sen Joaquin County Public Health- Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE--- INFO AMOUNT DUE AMOUNT REMITTED -_CASH RECEIVED BY - -DATE . PERMIT NO. . EH 13-24[1`1EV.1/8 5) CH 14.24