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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 PEMIX EXPIRES 1 YEAR FROM. DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This application is made in compliance vith San Joa in County Ordinance No. 51+9 and 1 62 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address ��' City of Size/Acreage Owner's Name �rl_- oa,,:a CTU d �Address� ,IZ '' __. Phone Contractor `Address --L-icense:No:/ J - •O- Phone{ TYPE OF WELL/PUMP: V NEW.,VVELL ❑ +. U -:Z WELL REPLA EMENT -D �' DESTRUCTION-D Nt of Service Well ❑ PUMP INSTALLATION ❑ t SYST REPAIfi ❑ ' OTHER ❑ Moriitoriit�g well ❑ DISTANCE TO NEAREST: EPTIC i7ANK SEWER LI E5 t* `°DISPOSAL FLD' r PROP.:LINE'S I F.OUNOATION A-GRICULT WE WELL OTHER WELL M w PITS/SUMPS s INTENDED USE TYPE OF,WELL PROBLEM AREW CONSTRUCTION SPECIFICATIONS = '3 n industrial ❑ Open Botiom Cl Manteca ' `Dia. of Welk ExcaCtatian" - Dia. of Well Casing [I Domestic/Private ❑ Gravel Pack L1 Tracy Type of Casing Specifications I 1'i Public i-1 Other n Delt Depth of Grout Seal Type of Grout I I Irrigation i w.Approx. Depth I I E tern Surface Sedl installed by Repair Work Done ❑ Type of.Pump H. State Work Done ! Well Destruction ❑ Well Diameter Sealing Materiel & Depth t Depth j Filler Material Depth TYPE OF SEPTIC WORK: NEW INSTALILATION 11 REPAIR/ADDITION I f DESTR C�1 TIONJ I (No septic system permitted if Wblic se r is � liable wrthin 2 feet.l + installation will serve: Residence Commartiial- Other _ -r-- - Number of Ir ing units: Number of bedrooms Character of soil to a depth of 3 Feel: P �f Water table de" nth SEPTIC TANK' ❑ Type/Mfg CapacityZ(1 L_2_"'" No. Compartments r PKG. TREATMENT PLT. ❑ '' - #% Method of Disposal ! Distance to nearest: ° Well�_ foundation � Property Line LEACHING LINE ❑ No. & Length of lines SZA71,/ Tofal length/size , ld { FILTER BED ❑ Distance to nearest: Weil_� aundation '+- Property Lina ( I Y r SEEPAGE PITS 11 Depth , Size r I&--NumberAir I SUMPS El Distance to nearest: Well 1(2 Foundation r(} .Property {line M DISPOSAL PONDS ❑ f I 1 I hereby certify;that I have prepared this application and that the work will be done in accordance with San Joaquin county,ordininces, slate laws, and rules and regulations of the San Joaquin County- F-- --• -- ; E r- I 'J f Home owner of 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 pers "on 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 Californla." i iy 1V ^ p I The applic t usr call f I requir d insPections. Complete drawing on reverse side. y Signed f Title: —-- P Date 6 pEPARTMENT USE ONLY ;v .I' f*0t� Application Accepted by 1 Date Area Pit or Grout Inspection by e�- Date Final Inspection by ! Date Cv 27 Additional Comments: - Applicant - Return a1.1 copies.-to San Joaquin County Public Health gOA� Services, Environmental Health Permit/Services .-- — �-- 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 .y FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 6Y DATE PERM17'(NO. EH 94-26 ` v ��