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y APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)465--3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ED � 1�y� /g�� is Triplicate) j Application is ereby made San Joaquf 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� r7_p ]i/y_0 Job Address ` N_TC�tC 7«� UC- 5 �i-)Z4- M, " � � Lot Size/Acreage 2- PAs'Cc �Qwner's Name Address - l_31 .:1 ` ' Phone Aontractor N4"R%ATdress v � �— License No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER KCtori Well (] i 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 { Cl industrial ❑ Open Bottom D Manteca Dia. of Well Excavation A Dia. of Well Casing Cil Domestic/Private 0 Gravel Pack D Tracy Type of Casing 1Specilications F) Public Cl Other n Delta Depth of Grout Seal T s r Type of Grout I i Irrigation _ Approx. Depth I ) Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H,P. State Work Done _f 0 «�� Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material b Depth 4 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I i DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial,.W,. Other l Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth a SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, ❑ Method of Disposal 46 Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED D Distance to nearest. Well Foundation Property Lina SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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 applica t musxt mall for al r quired��)nspect• s. Complete drawing %n reverse side. �igned v'V Y+� b \ r•I Title: �Z 1 � '- f N � Date: 2_._ g f FO D>` RTMENT USE ONLY � w� Application Accepted by Dateyr3_7Area [/ Pit or Grout Inspection by Date Final Inspection by Date g� Additional Comments: a ��,,,,��// ,ems ✓� 4 6 a ve Applicant - Return all copies to: San�oaquin'c`ounty pubSic ealth r � � r� !/ Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEEeINFO AMOUNT DUE AMOUNT REMITTED CK CAIR RECEIVED BY DATE PERMIT'NO. . EH13.241REV.r/a51 EH 14.2e II '=-