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k APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 1 I PFJLMIT EXPIRES 1 YEAR FROM DATE ISSUM (Complete in Triplicate) i 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. .7 Job Address , U UJr U.ltl Q / JZ S -rK-IVCity Lot Size/Acreage Owner's Name L L o 1(n P i-A o_Ps Address M e Phone T-_pq q T Contractor "'� �f 1 W Address `!)1&) OoT License No.-SQ 2Phone 8 4*/7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION Al SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ 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 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing IVDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public Cl Other fl Delta Depth of Grout Seal Type of Grout 1111 Il Irritation _ _.Approx..Depth _1 I Eastern _ Surface Seal.l_nsta_Iled by. I Repair Work Done U Type,of Pump L s. H.P. ff State Work Done Well Destruction ❑ Well Diameter ' Sealing Material & Depth A�Il✓ /-J Depth Filler Material & Depth LA} l TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) i Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms .0 a Character of soil to a depth of 3 feet: I Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ ti r x +Method of Disposal l'- Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size-- FILTER ength/site -FILTER BED ❑ Distance to nearest: Well Foundation - - Property Line 7 i SEEPAGE PITS 11 Depth Size _ Number SUMPS Ll Distance to nearest: Well Foundation PropertyFLine DISPOSAL PONDS ❑ G 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, 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 applicant mus I for all required inspections. Co pie a drawing onreverse ids. c 1 Title: —,r-( �C�_ 7 Date: Signed L FOR DEPARTMENT USE ONLY Application Accepted by CL. A Date Area 15 , Pit or Grout Inspection by Date Final Inspection by - Date 1 41 Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Sox 2009, Stockton, CA 95201FEE D INFO AMO�U-NT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO, EH 13-21 fREY.I/x 51 ` CyJ EH i1-2e J