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t APPLICATION FOR PERMIT � 3 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468--3420 P 0 BOX 2009, STOCKTON, CA 95201 EXPIRES 1 YEAR FROM DATE IS511ED (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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health rvi es. srn �•� srar,,�+ ��y Job Address f1✓ �W-070-0& O pSSW G� O`_ -r"WW 4 City S7 -( Lot Size/Acreage 67 rCn Ov`yr/per's Name AG 24.465 LA",0 Co Address kk rQ 1 14902 �'� 57� Phone 2 7 - 2ao %C 6JLL Fr/&,10S) eXet- V Contractor LAA Address O SAH License No. Zo'7va Phone 914-17142167 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION o Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 07HER �{� Monitoring well C1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL f=LDC��4P QP.NIC-LIE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPEC!FICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1 12 Dia. of Well Casing CI Domestic I Private ❑ Gravel Pack ❑ Tracy Type of Casing � Specifications i"1 Public 1-1 Other n Delta Depth of Grout Seal f%Y110V 17 Type of GroutOlt- GASt tet" i I Irrigation _.Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction O Well Diameter Sealing Material & Depth Depth Filler Material & Depth 450n, ( [V IN A-lnl4v rZ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/sue FILTER BED ❑ Distance to nearest: Well Foundation Propeny Lina SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line 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 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 applicant m call for all to it inspections. Complete drawing on reverse side. �e Signed r �- Title: . y��7�� __ I _ -__.__ _ Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by I Hate Final Inspection bhp _ Additional Comments: ___ti� j �-/U Applicant - Return all copies to: San Joaquin County Public Health ..1� Services, Environmental Health Permit/Services �\ 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK FI RECEIVED BY DATE PERMI7'NO. EH ts-24rREv,1/851 EH 11-26 G•� t 1 1