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APPLICATION FOR PERMIT SAN .QUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION ' 1601 E. HAZELTON AVE. , PHONE (209)468-3420 r P O BOR 2009, STOCKTON, CA 95201 ,PERXIT EXPIRES 1 YEAR FROM DATE ISSUED (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 co�liance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Addressj�r� �I�� / S' Sr�� " '" City � Lot Size/Acreage Owner's Nam - �� C(/•ress �15Address �� r /ZCU/VF Phone ,07 2Contracto { J{illAddC A-C License No. Phone� V-` /&_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAI�X ttJR ✓ OTHER O onitoring Well O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINEZ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE -- TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Q Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing (l Domestic/Private Gravel Pack ❑ Tracy Type of Casing Specifications I'I Public Cl Other n Delta Depth of Grout Seal Type of Grout - I I Initiation Approx. De ih I I Eastern Surface Seal Installed by Repair Work Done 1< Type of Pump H.P. St ork Done (i(N S� LCMSF Well Destruction Well Diameter a� Sealing Material t'. Depth = Depth _2) Filler Material i Depth �^ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms 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 L1 No. $ Length of lines Total length/size FILTER BED ❑ Distance to nearest. Well 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 Home owner or licensed agent's signatu a Certifies the folldwirig "I Certify that in the performance of the work for which this permit is issued, I shall not employ any person such manner as t become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the folio g: "I certify that' e performance of the work for which this perrhit is issued, I shall employ persons subject to workman's compensa- tion lows of C f la." The applicant t call for all re I i ct`ions. Complete drawing on v rse side. Signed Title: 1/I� �I✓ ^Z3 Wil/ Date: � O ONLY Application Accepted by Date_ 1�-13" Area >I Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Pnviroamental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMI7'N0. INFO CASH EH 142 111EV.rind P� �S.oC.� S 0o 5srl EH t�.2a � yl-2�q