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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 EXPIRES 1 YEAR FROM DATE �ID (Complete in Triplicate) Application is hereby trade 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. or City C vo l Lot Size/Acreage — Job Address 7- F Phone Owner's Name Address '"' Q 12S11 cSul License No. - S 7;7,Phone Contractor..- Address r TYPE OF WELL/PUMP: NEW WELL ❑ WELL. REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C1Monitoring Well L7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES- FOUNDATION FLO. PROP. LINE _ FOUNDATIO_N_ AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Type of Casing Specifications [:] Domestic lPrivate ❑ Gravel Pack ❑ Tracy Type of Grout i'1 Public (-I Other n Delta Depth of Grout Seal Q �_.Approx. Depth I I Eastern Surface Seal Installed by I I Irrigation State Work Oona Repair Work Done C7 Type of Pump H.P. _ Sealing Material & Depth Well Destruction ❑ Well Diameter Filler Material & Depth I t Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR IADDITIONkr–DESTRUCTION l I-availseptic system m permitted if public sewer is Installation will serve: Residence— .Commercial_Other Number of living units: Number of bedroo s 1 Character of soil to a depth of 3 feet: _ Lo'. t Water table depth a SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Ll No..& Length of lines Total length/size 6 f FILTER BED 1 1-1 Distance to nearest: ell Property Line f I } Foundation 4= R� SEEPAGE PITS IeT—Depth Size 3_ 0N1umber Ll Distance to nearest: Well /Q f (Foundation-� L._� Property Line SUMPS � ; + 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 taws, and rules and regulations of the San Joaquin County "�. f '1 Home owner or licensed agent's signature certifies the following: "I certify that i. the_performance of the work.#or which this permit is issued. I shall not employ any person in such manner as to become subject to workman's compensation laws of Csfifo n a.'� 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 spplican�ust call or all raqu ed in ctions. Complete drawing an r verse side. f — Title: '�4^ date: Signed X ' EPARTfMAENT USE ONLY 1 j i U Application Accepted by Date Area t / //ffly it or Grout Inspection by Date �/ 14 Final Inspection by ate Additional Cofnments: Applicant ^ Return all copies to: San Joaquin County Public Health I Services, Environmental Health Permit/Services l 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 l FEE AMOUNT DUfi AMOUNT REMITTED C K RECEIVED BY DATE PERM11'NO. . EH 17-24 tREV.i i x 5l �(J z C�j/17/ EH 14-H