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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 0 BOX 2009, STOCKTON, CA 95201 REMIT EXP RES 1 YEAR FROM DATE ISSUED /503/� 1�j'Y�/ /J-"�0�� (�C mp�l,',t� in Triplicate) � Application is ereby made,4 San Joalqui 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. K1 (�,��`Tit -C Lot Size/Acreage 2- AC'_( 4-S Job Address Kwner's Name Address — �—�1 1 J Phone License No. `-:'G ;l 8) Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT L] DESTRUCTION ❑ Out of Service Nell ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER tori Weli Cl 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 * industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i * Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing /Specifications ' I'l Public f:l Other n Delta Depth of Grout Seal 5 r Type of Grout I I irrigation Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth w Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is Cy`} available within 200 feet.l Installation will serve: Residence.......,.. Commercial — Other 1 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. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED CI Distance to nearest: Wel! Foundation Property Line SEEPAGE PITS 11 Depth Size _ Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 i 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 apOca must call for at r quire nspsct'o s. Cp�ymplate drawing qn reverse side. _ igned :J'V�t� t I Title: ,k�t?Q� �~ '�yf F�4l�irC4 Date: FO DE RTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date g� Additional Comments: 4.g e I-o2k= 4o a w o vt r kit f✓1° Applicant Return all copies to: SanloZaquinrCounty��,r�// b is ealth rl Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. . EH 13-24(REV.t i n s �'� �j l 4 iwg 9�b� O EH 644.28 vV�' ss 0 EE w