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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE ENVIRONMENTAL HEALTH DIVISION APR 4 �59� 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 Box 2009, STOCKTON r CA 95201 ENVIRONMENTAL HEALTH RFRMIJ EXPIRES 1 YEAR FRPM DAM ISSUED PERMIT/SERVICES (Complete is 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 rMM10 C 14jcit V-\ Lot Size/Acreage Owner's Name _Ga� „7 66�L C-Q _ Address .-AAM AAe{ L id. Phon .s !7D t v�P_,StvJt'nt� EJr, x+`"rb3 ddressContractor �� License No. _ Phone Z --� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR L7 OTHER ❑ Monitoring Well'50 u w 11 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LANE —FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public C] Other F1 Delta Depth of Grout Seal to Type of Grout eAAfit? i I Irri a ion t ��+ �`�n� '�..ApproK. Depth �QEastern Surface Seal Installed by p it Work D rte EJ Type of Pump rt H.P. State Work Done , Well Destruction ❑ Well Diameter Sealing Material & Depth '� t Depth Filler Material & Depth (� TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIWADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is 1 Installation will serve: Residence— Commercial_____ Other available within 200 feet.) Number of living units: Number of bedrooms (� Character of soil to a depth of 3 feet: Water table depth \1 SEPTIC TANK ❑ Typo/Mfg Capacity _ No. Compartments t PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line i i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I i SEEPAGE PITS 11 Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line y Y DISPOSAL PONDS ❑ �• .. x I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state a, 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 alifamia." i ILA The appli ant u cat!f r requir inspections. Complete drawing on reverse side. _ k Signed Title: .; _ .102-� *P—A 1�O :-3. J.Sr Date: 3 FOR DEPARTMENT USE ONLY Application Accepted by Date GTITAreaPit or Grout Inspection by Data Final Inspection by Dat 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 y FEE AMOUNT DUE AMOUNT REMITTED CK INfOj CASH �RE EEIVID BY DATE PERMIT'NO. + EH 13-24 IAEV.i i n$I EH 7428 / — •/?/ /,Q (:! / !J !/ M