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APPLICATION FOR PERMIT '/ . � J SAN JOAQUIN COUNTY -PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468=3420 P O BOX 2009, STOCKTON, CA 95201 > I PERUTT %P RES 1 —BAR FROM DAT ED {Complete in Triplicate) Application is hereby made to San Joaquin County for a?permit to construct and/or install the work herein described, This apPlice,tion is made in compliance frith San Joaquin County Ordinance No.' 5h9 and 1862 and the Rules and Regulat Joaquin County Public Health Services. ions of San Job Address / City 1 Lot_Size/Acreage Owner's Name &'C O��P- p Address �� 11 f '' I �, Phone A 35 J 13 Contractor =dl U3 f�7 TYPE OF WELL/PUMP' Licerise~No. �� Phone F ! 3 NEW WELL .;-; WELL-REPLACEMENT PUMP INSTALLATION X DESTRUCTION okT Out of Service Well, SYSTEM AFFAIR 0 OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK C7 ----� SEWER LINES-'" �� DISPOSAL FLD. PROP. LINE N FOUNDATIOAGRICULTURE WELL INTENDED USE OTHER WELL PITS/SUMPS TYPE OF WELL PROBLEM AREA CONSTRUCTION'SPECIFICATIONS Cl Industrial ---—__- ❑ Open Bottom ❑�VFanteca ia.o�Gyeti Ex`cavatiori -^ °^ -" CW Domestic/Private , 1K Gravel Pack-- Dia• of Well Casing C7 Tracy ` rType of Casing r Ul I'I Public f-1 O her n _Delta a Specifications Depth of Grout Seal iL I # Irrigation �. A. --- H.�_� „ ..__ _ Type of Grout Approx. Depth I I Eastein - r Repair Work Done (� T . Surface Seal Installed by Type of Pump - �G� tl -_ H".P. # �! Well Destruction _ O Well Diameter Sealing Material 6 Dtptti State Wark Done_ �Q_ jDepth Filler"Materiel & Depth v J STYPE-OF SEPTIC WORK: MEW INSTALLATION I I REPAIR/ADDITION 1"-1 DESTRUCTION-1-111No septic system permitted if u o n p blic sewer is Installation will serve: Residence �r�->----} available within 200 feet.l Commercial-Other �� f Number of living units: Number of bedroomst _- Character of soil to a depth of 3 feet: �- SEPTIC TANK. ❑ Type/Mfg w Water table depth PKG. TREATMENT PLT.❑ CapacityNo. Compartments Distance to nearest: S,W r" Method of Disposal .>Foundation--= Property Line, LEACHING LINE ❑ No. & Length of liner FILTER BED CI Distance to nearest; Total length/size z Wall ` Foundation Property-Line-� SEEPAGE PITS Il Depth - �• 4 V SUMPS S1�e — Number > , LI Distance to nearest., . , Well Foundation s DISPOSAL PONDS ❑ Property LitieR I 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 d rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: employ any Person in such manner as to become subject to workman's comfy tpensation lhat in the awsoOf California. Contractowork for r's which orr sub-contracting lsignatu et tion la the following: "t certify that in the performance of the work for which this ermit is issued, !shall em to tion laws of California." P P Y persons subject to workman's compensa- tion applicjnt�mTfst'Call for.all required ins ctions. Complete wing on reverse side. I� Signed X ''J� Title; 1 2 — 2 r — V Date; I fg _ FOR DEPARTMENT USE ONLY Application Accepted by Pito rou Inspection Date b ;I Date Final Inspection by Additional Comments: Q LO_ nDate ��cCr J . Agylict►nt - Return all copies to: San Joaquin County Public Health Q� Cd � dr/ Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE CK INFO AMOUNT REMITTED RECEIVED BY CASH DATE PERMIT'NO. . EN 13-21 fREV.+i m5) ' + E p EH 71.2" �'3y °a� 10- a,