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APPLICATION FOR PERMIT /� pr,-K I Lj� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION I 1601 E. HAZELTON AVE. , PHONE (209)468-3426 /� ]o � �/� / /� P O BOR 2009, STOCKTON, CA 95201 � V PERMIT FMIRES 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 Elan Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. / k Job Address �7s ,Ic p-l.S /r7- City S' ►_K/U Lot Size/Acreage Owner's Name ,�i��d> _ P>e._(7L _ Address /"-3 -3 `-' Phone Contractor Address License No. Phone { TYPE OF WELL/PU NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service well ❑ r PUMP INSTALLATION 0 SYSTEM REPAIR ❑. _ OTHER p Monitoring well C7 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 Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications I'I Public Cl Other n Delta Depth of Grout Seal Type of Grout I 11 Irrigation ....w.Approx. Depth I I EasternSurface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Weft Destruction O Well Diameter `Sealing Material & Depth 4 Depth [Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTIO ANo septic system permitted it public sewer is available within 200 feet.i Installation will serve: Residence Corlimerciat Other' r Number of living units: Number of bedrooms t Character of soil to a depth of 3 feet: C IWater table depth SEPTIC TANK ❑ 'Type/Mfg Capacity' No. Compartments 1 PKG. TREATMENT PLT.0 t � ' Method of Disposal i Distance to nearest: Well Foundation"` Property Line LEACHING LINE ❑ No. & Length of lines Total length/size i r FILTER BED Cf Distance tonearest: Well Foundation Property Line! " f � SEEPAGE PITS 11 Depth Size Number # SUMPS Ll Distance to nearest: Well Foundation Property Line ,} DISPOSAL PONDS Q 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 v I rules and regulations of the San Joaquin L County i 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 subcontracting 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 C a." The applic t must all for all require spections. Complete drawing on reverse side. Signed Title: Date: F DEPARTMENT USE ONLY Application Accepted by J Date _7 Z " Area �1 Pit or Grout Inspection by i Date Final Inspection by� ` Data� d 1 Additional Comments: �d / 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 FEE AMOUNT DU AMOUNT REMITTEDH RECEIVED BY DATE PERMIT NO. INFO EH 13"21[REV,I/x Sl ,`��J (Jv v S --S�f O b— 799 r EH i�•26 I