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r J ' APPLICATION FOR PERMIT - r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application 1s hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This I 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 Services. - i Job Address u�J +�It City JCX `-f— Lot Size/Acreage Owner's Name ; Cl � Address `'ytG _ Phone Contractor� � �J-�f' Address R6 0 License No, Phone TYPE OF WELL/PUMP: _ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ x- --••- "�Moni toying We]1 PUMP INSTALLATION ❑ ��SYSTEM REPAIR ElOTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ) E DISPOSAL FMD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS !; I Industrial ❑ Open Bottom ❑ Manteca Dia: of Well Excavation Dia of Well Casing, I 1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f /� l i'1 Public F1 Other I^1 Delta t Depth of Grout Seal Type of Grout f I1 i I Irrigation —.Approx. Depth ( I Eastern Surface Seal Installed by _ Repair Work Done U Type of Pump H.P. ..State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth I Filler'Materiel i Depth f� I ' TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADOITION DESTRUCTION I t INo septic system permitted it public sewer is t available within-200 feet.) Installation will serve: Residence v Commercial,____ Other Number of living units: _. _ Number of bedrooms — j • ! .. _ t" / i Character of soil to a depth of 3 feel: 0 r4n t "" Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity "'��' ;•No:Compartments T k PKG, TREATMENT PLT. ❑ Method of Disposal V� Distance to nearest: Well t Foundation t Property Line LEACHING LINE No.`& Length of lines H� f To4al length/site V r FILTER BED Q Distance.io nearest: Well_f[��i Foundation — Property Line r /��!� SEEPAGE PITS 11 Depth Size I rte•- �' • f° Number I 1 SUMPS I Distance to nearest: Well Foundatiorf.�_ Property Line _ DISPOSAL PONDS ❑ t f j I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laves, 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'k 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 required Inspections. Complete drawing on reverse ids S Signed t Title:- Date: 0011 FO E ONLY -- Application Accepted by j Date Ar I Pit or Grout Inspection by Date Final Inspection b Date Additional Ctxnmants: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services f 1601 S. Hazelton Ave., P 0 Box 2009. Stockton. CA 95201 FEE INFO AMOUNT DUE. AMOUNT REMITTED GASH CK RECEIVED BY. DATE' /`� P+ERMIT NO. . EH 13.24 Im.r i n Bi EH 74-25 - j`. r