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IM APPLICATION FOR PERMIT I� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ! ENVIRONMENTAL HEALTH DIVISION I� 1116501 E. HAZELTON AVE. , PHONE (209)468-3420 i P 0 BOR 2009, STOCKTON, CA 95201 A M I REMIT EXPIRES 3 YEAR FROM DATE_ISSUED_ x (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. Job Addresl� - ! .7-n� �p� Q City�1J1�Lot Size/Acreage I it - I i Owner's Name t)f khn� Address ' ) J� �9 ��3L - Phone ?�t�r f � NIi License Na Phone Contractor� �!�� __Address � . _, - TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT M DESTRUCTION ❑ Out of Service Weil: ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C._ Monitoring well] ❑ #1" DISTANCEJO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. '.RROP. LANE i !I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS u 1 s INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION. SPECIFICATIONS C7 Industrial` ❑ Open Bottom 177 Manteca Dia- of Well Excavation' Dia. of Well Casing - D Domestic/Private ❑ Gravel Pack ❑ Tracy- Type of Casing —_ Specifications I'1 Public Ij C7 Other i' Fl Delta Depth of Grout Seal Type of Grout f f I I Irrigation) __ Appro v Depth f I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done j Well Destruction ❑ Well Diameter r i Sealing Material & Depth �t ii II Depth Filler Material & Depth r- ` TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRJADDITION -DESTRUCTION I I (No septic systempermitted it public sewer is Ii available within 200 feet.) Installation will serve: Residence Z Commercial s Other f Number of living units: . -- Number of bedrooms Character)of soil to a depth of 3 feet: Water table depth ., SEPTIC TANK. ❑- Type/Mfg i Capacity No. Compartments PKG. TREATMENT PLT. ❑ I, r `.� �' � � Method of Disposal � II Distance to nearest: WeII Foundation T___ Property Line ' LEACHING ALINE Q, No. & Length of lines r '� t� _ __ Total length/size --2jr FILTER BED ❑ Distance to nearest: Welt�Q ._ Foundation'. Q F� Property Lina SEEPAGE PITS I I . Depth Size `it' Number, j SUMPS LI`"Distance to nearest: Well Foundation—,Property Line t� DISPOSAL'!PONDS ❑ I hereby certify that I have prepared this application and that the work will be in accordance with San Joaquin county ordinances, state,laws, and rules and regulations of the San Joaquin County . I [" 1 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 1p'become subject to workman's compensation laws of Calif ornia.';,Contractor's hiring or sub-contracting signature t certifies the ifotlowing: "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 + i The applicant must calf for all required inspe,Ctioris. Complete drawing on reverse side. I I Signed X I� Title: - Date: Zd—_?•'S9o�r4 ._ II FO P T.USE ONLY,,,._..,,.,, ApplicationAcceptedby Date/ Area Pit or Grout Inspection by Date Final Inspection b Date/ Additional Comments: I t I r Applicant - Return all copies to: San Joaquin County Public Health c Services, Environmental Health,Permit/Services 1601 E. Hazelton Ave.-, P 0 Box:2009, Stockton, CA 95201 w ._ FEE _ .a iNFO AMOUNT OtJ�S7^^ " AMOUtVT'REMITTED' �r H RECEIVED bAT£ / PERlvla'/No... . EH 13.24 MEV.1/K 5