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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 1.9iSUED ' (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 3662 and the Rules and Regulations of San 1 Joaquin County Public Health Services. Job Address City Lot Size/Acreage R Owner's Name ` 0 /1 r a- d i ii,_&eAddress - f_J �� r G�a�' `s•t.. Phone h (�, ��/1O[J�/7� 14/— %� License No. — Phone Contractor D I`� d_I//Vddress TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION'X SYSTEM REPAIR OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 17 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications r f'1 Public is Other C-1 Delta Depth of Grout Seal Type of Grout I f Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material &Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION i I lNo septic system permitted if public sewer is available within 200 feet.1 installation will serve: Residence_ Commercial— Other M Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth _ SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line F LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size _ Number SUMPS El 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, 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 tho ing: "1 certify that in the rformance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion law f Calif 'rn The a licant m st call for all r Ir, in coons. Co ate drawing on reverse side. Sign Title: , �� 9 CL-0-,L _ Date: JR ARTMENT USE ONLY Application Accepted by CLAN �,4 '""rr`L"�� Date __ _7� Area 1 t....,. _ .,..., ---,.__.,._, Pit or Grout Inspection by Date Final Inspection by Date0_ e Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, ktvironmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton., CA 95201 „q iFEO EE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 8Y DATE (�PERMIT'NQ'O. . EH 13-24{REV.1/n 5l EH 14.26 ( 4J{