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l APPLICATIJN FOR PERMIT r �'��a • SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ' ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AV PHONE (209)968-3420 P 0 BOX 2009, 6TOCKTON, CA 95201 PERMIT EXPIRES 1 1EAR FRAM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permij to construct and/or install the work herein described. This application is made in eampliance with Sa.A Joaquin County Or4nanee No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 7�.3� ,-t City 5�� Lot Size/Acreage i Owner's Name e/6�L �/ZrO:' Address PD_ 211 -, f4,) >Sd 6".I Phone Yal ti?S;1._?Y, [ Contractor Address -• License No., J2LYZ .!t Phoneme II TYPE OF WELL/PUMP: NEW WELL ❑ WELL RIPLACEMENT Q• a DESTRUCTION L7 Out of Service well O .r✓ ^_3 ' PUMP INSTALLATION-C SY TEM REPAIR ❑ OTHER 0 Monitoring well �7 DISTANCE TO NEAREST: SEPTIC TANK- SEWER LINES DISPOSAL FLO PROP'LINE —�`"'— I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ II INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom n Manteca Dialhof Well Excavation Dia. of Well Casing fl Domestic/Private ❑ Gravel Pack Cl-Tracy Ty of Casing Specifications Il Public I.) Other Il Delta Depth of Grout Seal Type of Grout a 11 Ircoation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L: Type of Pump N.P. Ir State Work Done' 1 Well Destruction O Well Diameter Sealing Material i Depth ' Depth Filler Matlial 6 Depth I► TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITIONIY, DESTRUCTION f I (No septic system permitted if public sewer is v +y � available within 200 (net.l \� Installation will serve: Residence T Cortu'ercial Y Ocher ;�, v -t Number of kvin units: Number of bedrooms g x Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT.PLT..0_ � Method of Disposal Distance to nearest: Well Anclation ____ Property Line ,, LEACHING LINE No. & Length of lines. �" `1_/64 Total length/.size i FILTER BED CI Distance to nearest: Well do 'I " Foundation - l0 Property Line M r SEEPAGE PITS Or Depth 2� Size_-_-_3311 Number a SUMPS r LI Distance to nearest: Well f r Foundation_Zip Property Line !6 DISPOSAL PONDS 0 0 . n I hereby certify that I have prepared this application and that the work will -done in accordance with San Joaquin county ordinances, stale laws, and rubs and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "1 certify t at 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 comlensation laws of California."Contractor's hiring of sub-contracting signature certifies the following:"I certify that in The performance of the work for whicji this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required in ctions. Complete drawing on larse side, t sC � IQ Signed X e Title: �t Date: R DEPARTM66ENT USE ONLY Application Accepted by J,_ r� Date Area Pit or Grout Inspection by Date 1L Final Inspection by DateLLf/� �` Additional Comments: Applicant - Return &U.-copies to:4.San Joaquin County Public #ealth Services, 93vironmental Redlth Permit/Services Y, 1601 E. Hazelton Ave., P 0Irx 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED C IH RECEIVED BY �n DATE ERMiT NO. EH 1344 Ir1EV.v Rat T EH1..2a �O .o� �,�� oz _ ��Si o a1�z �t -