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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES d ENVIRONMENTAL HEALTH DIVISION 1501 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 ' EEMIT EXPIRES 1 YEAR FROM DATE ISSj3ED (Complete is 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 City fN�nc � ilLot Size/Acreage 1{g0zGk. Owner's Name sl >- Address _T 7! (�rf�®M id, _7 - Phone Contractor +�-� _ IN Address r ' License No�� Phone TYPE OF WELL/PUMP: NEW ELL WELL REPLACEMENT DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION' SYSTEM REPAIR © OTHER ❑ Monitoring well L7 DISTANCE TO NEAREST: SEPTIC TANK -sem �- SEWER LINES DISPOSAL FLO.��-----hh�T PROP. LINE _ FOUNDATION.; . AGRICULTURE WELL OTHER WELL�L — PITS/SUMPS AW T` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r P industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack L1 Tracy Type of Casings ,fe— Specifications; I'} Public f.1 Other n Delta Depth of Grout Seal Type-of 1f out�ltae t I I Irrigation O�Approx. Depth I I Eastern ` rfaee Seat Installed by t A �.V �i2f ! l h� Repair Work Done ❑ Type of Pump 5 _ H.P. 1 ? State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth \ Fir Material 6 Depth e \ TYPE OF SEPTIC WORK: NEW INS T TION I I REPAIR ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.] 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 Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of fines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI 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 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 cenifies 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 ap icant m t call for all req red ' pections. Corgplete drawing on reverse side. Signed Title: . r >�C� - Date: z/l OR DEPARTMENT USE ONLY Application Accepted by Date' 4 9 Area r. Pit orro t Inspection by D t ' O Final Ins ection by S�Y Date Additional Comments: / Applicant - Return all copies to: Saga Joaquin County Public Health Services, Environmental Health Permit/Services Q^ 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201FEE INFO LINT DUE AMOUNT REMITTED CASH RECEIVED 19Y DATE PERM17'N0. 1 EH 13.24 iREV.tiny / / C� a /1