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y r s APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STtOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE (Complete in Triplicate) Application is hereby made.to San Joaquin County for a permit to construct and/or install the wo,cK�l described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1802,and the Rules � lations of San Joaquin County Public Health Services. "y Job Address /�""'�' e I I �r" ,�� M City ` '�'� Lot�dia-AAcreage 'L AC/-p— Owner's Name / ell Address Phone Contractor W00 %,c, �� n Address 0 ( "'R •OL�Cense fV f C� 5 16 3 Phone—�� TYPE OF WELL/PUMP' REW WELL O WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATIO.r O SYSTEM RE�IR O ,OT/HER � Monitoring Well L; DISTANCE TO NEAREST: SEPTIC TANK N)' SEWER LINES 100 DISPOSAL FLO. N6 PROP. LINE 0d FOUNDATION P—��— AGRICULTURE WELL 1 M' OTHER WELL PITS/SUMPS r " INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Sege//1/L-'rS CJS Industrial O Open Bottom K Manteca Dia. of Well Excavation Dia. of Well Casing �Rt pu Domestic/Private 0 Gravel Pack O Tracy Type of Casing Specifications UI"I Public f�4 Other n Delta Depth of Grout Seal Ty of Grout w I 1 Irrigation `�, Approx. Depthl I Eastern Surface Seel Installed by Repair Work Done 0 Type of Pump �_ H.P. State Work Done _ Well Destruction O Well Diameter _ Sen) Material 6 Depth Depth If�1 Pi teritil 6 Depth VC-At4,tit G - ¢ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR ION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Co orcisI O Number of living units: Number of r ms Character of soil to a depth of 3 feet: 0&1able depth SEPTIC TANK 0 Type/Mf mpartments PKG. TREATMENT PLT, O RE FED t od f Disposal Distanc - t: Well F oLine LEACHING LINE ❑ No. & Length4f linea l.aNI, siz i� �F,:• I FILTER BED O Distance to nearest: EfWell �� otxerty Line SEEPAGE PITS I 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, state laws, and rules and regulations of the San Joaquin County Home owner or licensad 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/trust ca21fyall required inspections. Comp)jte drawing on reverse side. _ Signed X tCtr"i 'S �� Al h9� 11 Title: 7 �1 F R DEPARTMENT USE ONLY Application Accepted by Da Are L3 Pit or Grout Inspection by ate 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 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH EH 13 24(REV.Ike 5) EH 14.2e