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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 O BOX 2009, STOCKTON, CA 95201 gERI[IT EXPIRES 1 YEAR_FRQH_DATE IS5UED (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. r Job Address / �]50 �yits_S0�,! City Lot Size/Acreage I Owner's Name dd(ess Phone Contractor--A e� Address �dY / � A�7en� License tlo 7f,f,� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR C} OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE .TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS P Industrial ❑ Open Bottom ❑ Manteca, Dia. of Well Excavation Dia. of Well Casing 17 Domestic/Private ❑ Gravel Pack D-Tracy Type-of Casing Specifications I'i Public fa Other „n Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth_ i I Eastern Surface Seal Installed by Repair Work Done 07 ; Type of Pump H.P. State Work Done _ i Well Destruction ❑ Well Diameter w Sealing Material & Depth ! Depth Filler Material & Depth TYPE OF SEPTIC'WORK: NEW INSTALLATION t I REPAIR/ADDITION DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial __ Other Number of living units: Number of bedrooms R Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg' Capacity No. Compartments PKG. TREATMENT PLT, ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length'of lines Total length/size FILTER BED Cf Distance to nearest: Well, Foundation aCd Property Line �r I SEEPAGE PITS 11 Depth r Size !S—;e !a sp Number SUMPS Ilk Distance to nearest: Well A20"'_ Foundation S0*77 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 licensed agent's signature cenifieg 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 signaturer�-�, 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 al required inspections. Complete drawing on reverse side. Signed Ay" Title: DL- Date: �-6; _'19� FOR DEPARTMENT USE ONLY I Application Accepted by Date Q Area L Pit or Grout Inspection by Date Final Inspection by L-LDate�d Additional Comments: Applicant - Return all copies to: San.Joaiquin County Public Health Services,-Bnvironmental•He&l h'-Permit/Services 1601',E. Hazelton Ave., P O Box 2009, Stockton,{CA 95201 INFO FEE AMOUNT pt1E AMOUNT REMITTED CASH RECEEVEp BY DATE PERM17'NO. . E/I17.21IREV.�iRSI -76 C - to-o-40 10- lib EM t�•2a