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' r APPLICATION FOR PERMIT . 'SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON..AVE. , PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 95201 RER IT EXPIRES 1_YEAR FROM DATE ISSUED (Complete in Triplicate) Application Is hereby made to Saa Joaquin County for a permit to construct and/or install the work'berein 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. 4 l Job AddressCity Lot Size%Acreage Owner's Name r A�!tJ[-y Address Phone Contractor �, r�. �-�G �P— Address License No. 7 Phone 90_5' 1� j TYP£_OF WELL/PUMP, wT _ _NEW WELL_0. _,_WELL,REPLACEM_ENT E) DES_TRUCTION_0 Out of Service Well ❑f PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ^Monitoring Well-L] DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing CJ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1"9 Public I-i Other n Delta Depth of Grout Seal Type of Grout 1. - I ! Irrigation r Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done LI , Type of Pump H.P. State Work Oona Well Destruction ❑ Well Diameter Sealing Material & Depth :� Depth t t Filler Material & Depth e TYPE OF SEPTIC WORK; NEW INSTALLATION )y REPAIR/ADOITIDN I I DESTRUCTION ! I lfVa septic system permitted SEPTIC. r1 P y pe tted'if public sewer is ' available within 200 feet.I ' 4 ,`Installation will serve,: Residence kf� Commercial— Other i ,Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:' Water table depth SEPTIC TANK i ❑ Type/Mfg Ca acit p y No. Compartments ' .21 PKG. TREATMENT PLT. ❑ u r; Method of Disposal ` S s Distance to nearest: Well 400Foundation Property Line - LEACHING-LINE, No. & Length of lines "` - Total length/size 6O FILTER BED 1 D Distance to nearest: Well a{`Foundation - 2 Fr j t Property"Line_,mss SEEPAi3E,PITSI ( I Depth Siie _ eg Number BLIMPS µ ' Distance to nearest: 1+Vell r- Foundarion6.ir��- -,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, 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 f�e•work for which this permit is issued, !shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hirinb or sub-contracting signature certifies the following: "I certify that in the performance of the work4or which this permit is issued, i shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all equire inspections. Complete drawing on reverse side. ; Signyd X - title: �7 Date: FOR,DEPARTMENT USE ONLY ` Application Accepted by flare Area 2/6 + Pit or Grout Inspection by bate Final Inspection by Date 'I) v r _ Additions! Comments: ,. • S' Applicant - Return a21 copies to:,,,San Joaquin County.Public Health' Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CIS' RECEIVED 8Y DATE riSEHM1T NO. r INFO CASH - � + EH 13-21 tREV.tiR$I - EH„-� ��s/y -7 I