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IN . APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICEaS 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) 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. L Job Address �u r �I--- ----------- City Lot Size/Acreage Owner's Name Q 1�e6ioAddress �Q S /�ii t i `fig Phone Contractor Address _�e� License No.gjo— JS1.Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION AV11- SYSTEM REP 11R ❑ OTHEfi ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK 400 ,�_ SEWER LINES /nD DISPOSAL FLDA9"E/ PROP. LINE Ab—) r FOUNDATION ink ` AGRICULTURE WELL 76THER WELL PITS/SUMPS /-00 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS N Industrial ❑ Open Bottom _T© Manteca Dia. of Well Excavation Dia. of-Well Casing Domestic/Private Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public „fOther i fl Delta Depth of Grout Seal IQ Type of Grout I I Irrigation �.Approx. Depth I I Eastern - _ 5ujjace Seal installed by Repair Work Done 0 Type of Pump �_ I H.P. State Work Done Well Destruction ❑ Well Diameter , > Sealing Material & Depth Depth ''r': Filler Material & Depth X15 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADOiTION I I DESTRUCTION I i (No septic system permitled if public sewer is t i available within 200 feet:) Installation will serve: Residence_ Commercial T_ 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. ❑ r Method of Disposal Distance to nearest: Well � � t Foundation Property-Line LEACHING LINE D No. & Length of lines Total length/size FILTER BED E) Distance to nearest: Well ' Foundation _ Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation— Property Line DISPOSAL PONDS El I hereby certify that I have prepared this application and that the work wilt 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: "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 subcontracting 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." 1 The applicanfor all re wired ins ctions. Complete drawing on reverse side. Signed Date: �= f _ Title: ' � � TMENT USE ONLY Application Accepted by Date__1�, "`h� Area Pit oGrout nspection byy�� f� Date i` �� Final Inspe on by t Date Additional Comments: � —�/ �d Applicant - Return copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 iFEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT N0. r EH 13-24(REV.v/h 51 ^ T/ EH 14.26 "� •� 53�$ ��Y D �( l7