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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 0 BOR 2009, STOCKTON, CA 95201 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 Services. Job Address rw1G W At)"n1 c✓ ttc �, City :'�L r l-�"� Lot Size/Acreage Owner's Name �e`` �v�J W�Y'S Address '`"`-c— h/)-' Sl�1�^-X Phone Contractor �hc c/rur , Fx >li ra fic Address �1C 5 �h` S%� `' Prone 1 �.License No: TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMFNT (-1 DESTRUCTION L-I Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR Ll OTHER O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK ti`s SEWER LINES 2 5 _ DISPOSAL FLD. PROP. LINE / (1 FOUNDATION _ N� AGRICULTURE WELL �'� OTHER WELL �' PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS rl Industrial El Open Bottom 11 Manteca Dia. of Well Excavation Dia. of Well Casing ? r 1 Domestic/Private M,Gravel Pack (1 Tracy Type of Casing___ L,C, Specifications I'1 Public I 1 Other RDelta Depth of Grout Seal _ "0 _ Type of Grout A ` ' C1•4 _ I I Initiation ___ Approx. Depth I I Eastern Surface Seal Installed byS `+li r_ Repair Work Done 0 Type of Pump H.P. — State Work Done _ Well Destruction O Well Diameter Sealing Material 6 Depth &'ro_ Depth Filler Material i Depth .2 A TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence _._ Commercial __ Other Number of living units: __ Number of bedrooms Character of soil to s depth of 3 feet: Water table depth SEPTIC TANK O ,Type/Mfg _ Capacity No. Compartments PKG, TREATMENT PLT. 11 Method of Disposal _ Distance to nearest: Well Foundation _ Property Line LEACHING LINE L No. & Length of lines ._ Total length/size__ FILTER BED CI Distance to nearest: Well Foundation . Property Line SEEPAGE PITS 11 Depth -_ Size _ _ __._ Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 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 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 allrequiredinspections. Complete drawing on reverse side. f Signed X_LAI, 6, IVTa Title: �.�`�� f�50 ?"F, 12Date: I I I �� /� C) FOR DEPARTMENT USE ONLY Application Accepted by (fit /Z/v✓ti��/i Date Area Pit or Grout Inspection by �^ � Date 4 91 Final Inspection by Date g! 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 FEE INFO AMOUNT DUE AMO`+UUNT REMITTED CASH CK RECEIVED BY DATE PERMIT NO. • EH 142a /�6IREV EH �(� 1