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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-342.0 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES X YEAR FROM DATE ISSUFD_? x ! (Complete in Triplicate) Application is hereby made.to San Joaquin County far a permit to construct and/or install the work herein described. This application is trade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Sat} Joaquin County Public Health Services. Job Address ��3'Sa " Z-*W5 City Lot "Size/Acreage Owner's Name �'g � SwEEr Address /. o, B o>t (57 eLICA145--urs Phone 759-3311 Contractor [ ' G��"` i Address y7�J �� License No. Phone 1 TYPE OF WELL/PUMP: NEWrWELL ❑ WELL REPLACEMENT ❑. DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 'OTHER ❑ Monitoring Well [7 DISTANCE TO NEAREST, SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL I PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f:l Industrial ❑ Open Bottom. ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ' ['i Domestic/Private 0 Gravel Pack D Tracy Type of Casing Specifications I'I Public Cl Other n Delta Depth of Grout Seal Type of Grout "} I i Irrillauon __.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done Ll Type of Pump f H.P. State Work Dore Y Well Destruction 0 Well Diameter ' sealing Hnterial i Depth Depth j Filler Material i Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I I "REPAIR/ADDITION I i DESTRUCTIO INo septid system permitted if public sower is .4 available Within 200 feet.l Installation will serve: Residence — Commercial_ Other r Number of living units: Number of bedrooms I Character of soil to a depth of 3 feel: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, 0 Method of Disposal Distance to nearest; Well Foundation Property Line r LEACHING LINE 0 No. 8 Length of lines Total length/size FILTER BED CI Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth f Size Number r SUMPS 1.1 Distance to nearest: Well Foundation Property Line . DISPOSAL PONDS O I hereby canity, 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 certifies the following: "I certify that in the performance of the work for which this permit is issued. I shalt not employ any person in such manner as to become subject to workman's compensation taws of California." Contractor's hiring or subcontracting signature certifies the following; "I certify that in the perfofmance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion lows of California." The applicant must Cali for all required inspaetions. Complete drawing on reverse side. Signed X . Title: Date: p FOR DEPARTMENT USE ONLY Application Accepted by 1 - �A../LL'aDate 71 Iq n Area Pit ur Grout Inspection by Date Final Inspection by :�6ADat ' Addi 'conal Comments: ante: Applicant - Return all copies to: San Joaquin County.Public Health Services, Environmental Health Permit/Services Ne 1601 F. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 INFO AMOUNT Pt1E AMOUNT REMITTED C Sli RECEIVED BY PATE PERMIT'NO. EH 13"24 IAEV,I/n sr ,T ��` 7 �` �/9{� !"'"r(�p�r3 EN .4 26