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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 BOR 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Applicationishereby made.to San Joaquin County for a permit to construct and/or install the work iaerein 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. � (� ,Job Address j a/��a� Ay City �1-S4,1 "c.Lot Size/Acreage owner's Name <�—�/ Address Phone 4(6 '-X Contractor ``� Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 0 DISTANCE TO NEAREST: SEPTIC TANK -SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION, ---AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL� PROBLEM AREA CONSTRUCTION SPECIFICATIONS 71 n Industrial ' ❑ Open Bottom` ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 9 [I Domestic/Private �` ❑ Gravel Pack`. ❑ Tracy N Type of Casing Specifications Il Public Cl Other n Delta De th of Grout Seal Type of Grout P YP I I Irrigation Approx. Depth 'I 1 Easternti Surface Seal Installed by Repair Work Done U Type of Pump _ H.P.1 State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth i al Depth � -Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/-A-DDITIONe1,1_DESTRUCTION.1-1-1No.septic..system_permitted_i(p�iblic_seWer.is „ n 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- O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED CI Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size _ Number 6 SUMPS LI 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, andZ 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 applic ust c for ValIrquired s tions. Complete drawing on averse side. )1 Signed X Title: .- Date: ^ \ FO EPARTME_NT USE ONLY Application Accepted by d'^ J 1 Date Area Pit or Grout Inspection by s .? Date ?9 Final Inspection.by. Date Additional Comments: /4Z GSeP�r�iJu , 'fo Applicant — Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEEINFO AMOUNT DUE AMOUNT REMITTED CAK IT SH RECEIVED BY 'DATE PERMIT'NO. . EH 13-24IREV.iix51 0 c®� �� � EH 7428