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y� D APPLICATION FOR PERMIT ry SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468--3420 P O BOX 2009, STOC%TON, CA 95201 0 0 r , PERMIT EXPIRES 1 YEAR F'RQM DATE ISSUED (Complete in Triplicate) W ^� �J� rU 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 1962 and the Rules and Regulations of San Joaquin County Public Health Services. Job Addressia,-� q-3 IV :TGG UA.e J City Lot Size/Acreage -I -tea _tea Owner's Name L I Address A Phone`�� - Contractor l 1 Address (sdzy: License N0.Q1T2-1FS-1 Phone �=� TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 5ZDESTRUCTION Out of Service Well ❑ PUMP INSTALLATIONr SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK ~ SEWER LINES DISPOSAL FLO. PROP. LINE r�i FOUNDATION AGRICULTURE WELL OTHER WELL^ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATigNS � - F1 Industrial Open Bottom © Manteca Dia. of Well Excavation �� Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications �t I'! Public Olther ❑ Delta Depth of Grout Seal /AVAO Type of Grout(-r',M 4,41,17 I I Irritation Approx, Depth J I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. Q State Wo Done Weil Destruction � Well DiameterSealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I I DESTRUCTION l I (No septic system permitted it 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 r 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 lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS 0 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, ani 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 must call) for all required inspectionk-�omplete drawing on reverseside.side. V97) Signed JO 1,4 f�I A 4-A 1�Q¢nv� Title: S�/ I �- _ Date: 3 DEPARTMENT USE ONLY Applicatio epted by Date Area Pit Gction � Datv Final Inspection by Date � Additional Comments: - Applicant - Return all copies to: Ban Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE CK I INFO AMOUNT DUE AMOUNT REMITTED C/ApS�H.r� ]�R/-[E-CC(EIIIVVED BY 7//D/ATE PERMIT NaO. . EH13-21(REV.i/w51 131,©z7 �� ri.O0 C1 x— - `' !/ 3, � EH 71-24,