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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)465-3420 P O BOR 2009, STOCKTON, CA 95201 t EMIT EXPIRES 1 -YEAR-MOM DATE_ ISSUED (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 services. Job Address !7 4 S(:/(` City`aC e,60'd Lot Size/Acreage , SAMC fOwner's Namee<2W + Address Phone 6 cls 6 Contractor « e4/ G fs Address '✓ License No.a77��f Phone TYPE OF WELL/PUMP: NEW WELL $e WELL REPLACEMENT D DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION QK SYSTEM REPAIR 0 OTHER i] Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE �J FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ iINTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r C] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavatioi` Did. of Well Casing >eDomestic/Private Gravel Pack ❑ Tracy Type of Casing SLG Specifications f 11 Public D Other I ❑ Delta Depth of Grout Seal 5 e7 Type of Grout. �C 4^4 r 4 1 I Irrigation �► aC? Approxi Depth I I Eastern Surface Seal Installed by 4r FA- Repair Work Done U Type of Pump _ S Vb H,P. State Work Done_ ��"isxo Y Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth k TYPE OF SEPTIC WORK: NEW INSTALLATION I ] REPAIR/ADDITION i I DESTRUCTION I I (No septic syslam permittedrif pubiic,sawer is _ ,.-�- v- available-within'200 feet ) ,..� Instal latibn wili serve:--Residence-Commercial Other Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: , Water table depth (� SEPTIC,TANK 0 Type/Mfg ! Capacity - No. Compartments PKG. Tf EATMENT PLT, ❑ Method of Disposal Distance to nears§t: Well Foundation Property Line Il LEACHING LINE Cl No. & Length of fines Total length/size ! FILTER BED Cl Distance to nearest: € Well Foundation Property Line l { € a € SEEPAGE PITS 11 Depth 3 Size Number L SUMPSi LI Distance to nearest: � r Well Foundation Property tine I DISPOSAL PONDS ❑ ! d E I hereby cinify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordihances, state lawjan �rules and regulations of the San Joaquin County Home owner or licensed agent's signature cenifies the l following: "I certify that in the performance of the work for which this parmit is issued I shall not 1� employ any parson in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies thi.following:"l certify that.in.the-performance"of the work for which this permit is issued, I shall employ persons subject to workm`an's compensa- tion laws of California." I The applicant must al1 for all re fired inspections. Complete drawing on reverse side. Signed Title: _ Date: F--/=L— -- 91 .. - _. Y USE ONLY .. Application Accepted by " rDate :2%7t 1 Area t i Pit or 4t Inspection by 7 Date __ _ Final Inspection bye ` Additional Comments: t/ Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P Q,Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK INFO / CASH RECEIVED BY DATE PERMIT'NO. EH 13-24(REV,1/M51 W `� (� �j EH":4.26