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APPLICATION FOR PERMIT i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-8420 r P O BOR 2009, STOCgTON, CA 95201 EXPIRES 1 YEAR FROM DATE TRSURD (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 Servic a. ` t �. -ri City Lot Size/Acreage Job Address 4 � 3 1 a Phone _7 , 1�� Owner's Name Address Conhactor cess icense Na.lPhone (/ TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT C-:} DESTRUCTION ❑ Out of Service We11 ❑ PUMP INSTALLATION ❑ SY ❑ OTHER C7 Monitoring Well STEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES DISPOSAL FI-D. PROP. LINE Y ` FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .�.. INTENDED USE TYPE OF WELL , PROBLEM AREA CONSTRUCTION SPECIFICA710NS" 'Dia. of Well Casing R Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation s t Specifications»- -1�-- Fa Domestic I Private ❑ Gravel Pack 0 Tracy Type of Casing Type of Grout 1-1 Other R Delta Depth of Grout Seal 1'I Public I i Irritation Approx. Depth t I Eastern Surface-Seal Installed by` H P State Work Done _ Repair Work Done U Type of Pump Sealing Material S Depth Well Destruction E) Well Diameter Filler Material. & Depth f Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIRlADD1TION I 1 DESTRUCTION I I availabetrwi within 200 feet.Ied :p,,blicer isInstallation will serve: Residence ,Commercial Other Number of living units: !- Number of bedrooms_ -` --�- +t � Water table depth Character of soil to a depth of 3 feet: No. CompartmentsSEPTIC TANK D Type/Mfg' Capacity . r Method of Disposal PKG'TREATMENT PLT':❑ _ " ` Distance to nearest: Well Foundation Property Line ^ LEACHING LINE a Cl 'No. & Lerigth of lines Total lengthlsize 6 /l d Property Line FILTER BED Lf Distance to nearest: Well-e__ Foundation r SEEPAGE.PITS 1 1 Depth Size Number SUMPS l_I Distance to nearest: Well Foundation 0 Property Line 19 DISPOSAL PONDS ❑ It be done in accordance with San Joaquin county ordinances, state laws, and I hereby certify that I have prepared this application and that the work wi 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 j employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature j 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." Mf Theapplicant m t call for It re ed inspection Complete drawing on r�9varse side. /} Signed Title: (�- Date: (� FOR DEPARTMENT USE ONLY DateA=4�o- _Application Accepted byj�4 4 Date L/a- Final Inspection by 1!" or Grout inspection by fAdditional Comments: Applicant - Return all copies to: San Joaquin County Public Health a k i Services, Environmental,8ealth Permit/Services s` - s 1601 E. Hazelton Ave., P O,Box 2009, Stockton, CA 95201 ti e '`" CK RECEIVED By DATE PERMIT'NO. IF EENFO AMOUNT DUE AMOUNT REMITTED CASH k - G1 -�7 . EK 13-24(REV.+)R 5s /S� 1 0 -7 a3 _EH;ate i .