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APPLICATION FOR PERMIT r L SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 ;i 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 SVrvices. Job Address �' r c Cil Cit ZClCYC01 Lot Size/Acreage I Owner's Na Al ��0fI Address �L�'Q C� c��"r �T4 Phone Contrac ori Jl ,W, —L-C Address (7,!2d-- [A2,1_,_�/License No Y Phone 7S TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public 1-1 Other n Delta Depth of Grout Seal Type of Grout \ I I Irrigation — Approx. De I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. _. Y. State Work bone Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth r TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I i iNo septic system permitted if public sewer is available within 200 feet,) � Installation will serve: Residence^ Commercial_ Other f Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water-table depth SEPTIC TANK. ❑ Type/Mfg Capacity— No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal . i Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines} Total length/size FILTER BED CJ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size _ Number f SUMPS L1 Distance to nearest: Well Foundation Property Line 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 not employ any person in such manner as to became subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: •'I certify that in the rformance of the work for which this permit is issued, I shall employ persona subject to workman's compensa- tion laws of Cal fornia." The applica ust call for all required i tions. C mplete drawing on se aide. Signed X Title: Date: L • R DE�1RT SE ONLY � Application Accepted by .mss\\� L 1 . Date 3�,�_ Area C� �. Pit or Grout Inspection by Date Final Inspection by Lill 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 3 FEE AMOUNT DUE AMO NT REMITTED CK RECEIVED BY ATE PERMIT"N0. INFO T R CASH EH A•29