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APPLICATION FOR PERMIT i F PA V �. SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES � � � ENVIRONMENTAL HEAL�:(t H DIVISION MAR 2 0 r 1601 E. HAZELTON AVE. , PNE (209)468-3420 SAtV JO P O BOX 2009, STOCKN, CA 95201 �� N DATE ISSUM ��OL/11V � Y PFJCES WIT EXPIREete inATr pR. licate) Application H�LTHo/Vsorr (ComApplication is hereby made,to San Joaquin County for a permit to con and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance to. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. I Job Addres 1 LA- e rf�_ '� 1 r�!: Ci,y Lot Size/Acreage Owner's Name Address On Ph36 - - R xitn 15 /� 1L3'0� 54v" C Contractor Address �5� �• Ttei.S)r. License PIo5r2Z&3 Phone I&T M'2-- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACFN ENT ❑ DESTRUCTION Out of Service Well ❑ PUMP INSTALLATION O SYSTEM RE'AIR ❑ OTHER ❑ Monitoring well ❑ DISTANCE TO NEAREST: SEPTIC TANK�� SEWER LINES DISPOSAL FLD�a PROP. LINE FOUNDATION �, AGRICULTURE WELL OTHER WELL Ri);n::: PITS/SUMPS -2-15 f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCT ON SPECIFICATIONS vTAL. gq7�Lv� L] Industrial ❑ Open Bottom ❑ Manteca Ilia. of Well excavation Dia. of Well king ! !/ Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Cass gSpecifications I"1 Public Cl Other Cl Delta Depth of Gro t Seal Type of Grout I i Irrigation _.Approx. Depth l I Eastern Surface Sea nstalled by Repair Work Done 0 Type of Pump H.P. State YVork Done, Well Destruction X Well Diameter rt Sealing Material b Depth Depth sr Filler Material i pth (1PL l TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 1 DESTRUCTION l I (No septic system permitted if public sewer is available within 200 last.! 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 ranae ity 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 0 Distance to nearest: Well Foundatio Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be done ih 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 th;performance of the work for which this permit is issued, f shall not employ any person in such manner as to become subject to workman's compensatior 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 perrinit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applic t cap for al ired inspections. plate drawing on reverse si e Signed X Title: Date: FOR DEPARTMENA/SE ONLY Application Accepted by Date Area r Pit or Grout Inspection by Date l�F Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Pe t/Services 1601 E. Hazelton Ave., P O Box 20 9, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED J CK IVED BY DATE PERMIT'NO. INFO qq�� CASH (j /� . EH 13.24 MV.I/K5) $�� G •�/tJ �'3� ` !� ��-674 EH X1.26