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A1PPLICATION FOR PERMIT r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) rApplication 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. r . Job Address � City Lot Size/Acreage y��.�t Phone Owner's Name- �ltlSrhss, � ,. ._-...w I�f''� lde3 Address +� ��` Wii�ense tio. r yll VS honed Contractor .. TYPE OF WELL/PUMP"i'�-,�.,€ NEW WELL ❑ WELL,REPLACEMENT 11 DESTRUCTION ❑ Out of Service Well ❑ ��7� PUMP INSTALLATION ❑ r SYSTEM REPAIR ❑ OTHER ❑ Monitoring well �f� DISPOSAL FLD. PROP. LINE DISTANCE;70 NEAREST: SEPTIC TANK -- SEWER LINES ^, 1{ " FOUNDATION " _ AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE I ,T-YPE OF WELL- PR68LEM AREA E CONSTRUCTION SPECIFICATIONS y M Industrial E OpenAottom s Cl Manteca I Dia. of.Wall Excavation Dia. of Well Casing - ^ f P Domestic/Private [(.0 Gravel Pack r V ❑ Tracy ' Type of Casing Specifications r 1'! Public J `1=1 Other 1 r fl Delta a Depth of Grout Seal Type of Grout r I i Irrigation .Approx."Depth 11 Eastern Surface Seal Installed by ¢ 3 r, Repair Work Done U Type of Pu p H.P. State Work Done,2L_ Well Destruction O Well Diameter $ ; Sealing Material & Depth } - "" Depth Filler;Material & Depth t 1 f TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/AODITIO DESTRUCTION I 1 iNo septic system permitted if public sewer is t x available within 200 feet.! Installation will serve: Residence Commercial Other Number of living units:V Number of bedroonrls Character of soil to a depth of 3 feet: ` t Water table depth ` SEPTIC TANK. U Type/Mfg f Capacity_____L_ No. Compartments PKG. TREATMENT PLT. Cly Method of Disposal ,a Distance to nearest: : Well Foundation Property Line t ; LEACHING LINE C1 No. & Length of lines '� ` Total length/size r FILTER HED n Distance to nearest:, Walt t� '!Foundation Property Line � SEEPAGE PITS, Size v ' E ` Number SUMPS UI Distance to nearest:! �ell 'r .r Foundwicin Property Line . DISPOSAL PONDS ❑1 r ` e I hereby certify that I have prepared this applicat on avid that the work will be done in accordance with San Joaquin county ordinances, state laws, and -•� rules and regulations of the San`Joaquin County( �+ i P Home owner or licensed agent's srgnature 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 td become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in ttie performance-of the-work for which this permit is issued,.1 shall employ persons subject to workman's compensa- tion laws of California." ` .J r ' `g, �r iI f The applicant must c fl r all req tions. Complete-dravving.on reverse side. 3 .. i d ff Signed X f�itla: t Date: FOR DEPARTMENT USE ONLY ' Application Accepted by Dater - Are al - ,� 4�i or Grout Inspection-byT Date 9L _ !L Final Inspection b i Additional Comments: > }�° r 4 f Applicant - Return all copies to: San Joaquin County Public Health i Services, Lnvironmentsl Health Perr51't/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT Dt1Ef OUNT REMITTED CK RECEIVED BY DATE - PERMIT'NO. k INFO CASH 7 f {� + EEH Fi?�24IREV.I/" tO� f t;,J V H'1 --