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APPLICATION FOR PERMIT — SAN �AQUIN COUNTY PUBLIC HEALTH SEICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$--3420 P 0 BOX 2009, STOCKTON, CA 95201 PFJt91J 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 1662 and the Rules and Regulations of San Joaquin County Public Health Services. `j� Job Address ` ;� - City [ C Lot Size/Acreage Owner's Name ©�� " � Address PO S(? �� Phone '70 IMt 1GH(5(._L DrZfLL( NG9/6 £37 Z-9 ,e Contractor (=f�V 1 ©W��1L'WTAE- G b;2p Address 2'C S + CNrtA !� = icense No. ' Phone 20`L 723 - TYPE OF WELL/PUMP: NEW WELL-'R_' WELL REPLACEMENT F.1 DESTRUCTION C} Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER ❑ Monitoring Well MSTANCE TO NEAREST: SEPTIC TANK �O f SEWER LINES > f OsJ DISPOSAL FLD. >102f PROP. LINE f FOUNDATION AGRICULTURE WELLI I_' I OTHER WELL! I PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ZI t Dia. of Well Casing C.� Industrial r,Gl Open Bottom ❑ Manteca Oia. of WeEI Excavation 9 � I C.} Domestic!Private btu Gravel Pack Tracy Type of Casing pV 5pecification5� �.]�L�L G. L-pT Public C1 Other F- Delta Depth of Grout Seal 2- ( Type of Grout C�t2TL I I Irrigation Zd.Approx. Depth I i &astern Surface Seal Installed by Repair Work Done U Type of Pump �� _ H.P. State Work Done Well Destruction ❑ Well Diameter f Sealing Material & Depth v Depth 20 Filler Material & Depth V TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 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 a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. El Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS ( I Depth Size _ Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stale 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, 1 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 appficant m °'ca I for all equ'red ins ti s Co a drawing on reverse side. Signed X i Title: f eS�d aL Date:FOR DEPARTMENT USE ONLY .G tf Application Accepted by _ _ ! Date t f Area' t� Pit or Grout inspection by Date jv Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 B 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED K INFO RECEIVED BY DATE PERMIT N0. rJ� r /y ) . EH 13-24[REV. /H 5 EH;1-26 1 �"'` � _A�'�,Q� (fir ' (/t 3!/S -