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I APPLICATION FOR PERMIT t SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1„ YEAR FROM DAIS ISSUED (Complete in Triplicate) II Application is hereby made.to San Joaquin County for a permit to construct and/or install the work herein described. This 1 application is made in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. �` Job Address _�6 / � a lat A CityCt"AA/)Lot Size/Acreage �G 3 �_� � Owner's Name Address 7 Q�a +n Phone y Contractor _ / /h' Address E'/).4&*4- �ei License No S Phane cf� TYPE OF WELL/PUMP: f NEW W TL>C -'"' WELL REPLACEMENT- 0" - DESTRUCTION^❑-Out`of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR C OTHER Q Monitoring well L7 DISTANCE TO NEAREST: SEPTIC TANK ZO 0 ,- SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL_ PITS/SUMPS fS� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIgNS �- n Industrial Open Bottom ❑ Manteca Dia. of Well Excavation �e � Dia. of Well Casing C )<Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing e�f Specifications + I'l Public 1-1 Other n Delta DepthofGrout Seal aeor Type ;f GroutzTeh"°i'r��_ I I Irrigation p94�.Approx. Depth I I Eastern � Surface Seal Installed by 1 2'� 12.) ! `G Repair Work Done ❑ -`Type of Pump H.P, //aZ _ State Work Done 1�" Well Destruction ❑ -Well Diameter Sealing Material & Depth ,,Depth Filler Material & Depth = TYPE Of SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is 'y 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 i 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.lengthIsize —_ FILTER BED 1I Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1.1 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line - DISPOSAL PONDS 0 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: "1 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 canifies 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 inspections.-Complete drawing on reverse side. :I Signed Title: S��' Ji✓.['rfs r' Date: - If FOR DEPARTMENT USE ONLY Applicatio>ommienta: ted by 11 Date Q A0 Area Pi ,`b 'Insction by Date Final Inspection by Additio - - - " Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services , 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 INTO FEEOUNT DUE AMOUNT REMITTED CASCK 9 H RECEIVED BY DATE PERM17 N0, r £H13-21rREV.11n51 EH 11.25 I ` 7 '