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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 PE MIT 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 P`uubblliic Health Services. ,� /f Job Address +�✓ t ^enl r r1L4 „ City �4t ' , Lot Size/Acreage e So ��/ Owner's Name Address !sy 'y' 14 - 5 • Phone Contractor r_ 6-d Address -[& 'T 5 16tteVk40. License No. I Phone 47 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing F] Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public i..1 Other FI Delta Depth of Grout Seal Type of Grout 1 1 Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L3 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth �1 TYPE OF SEPTIC WORK: NEW {NSTALLATION REPAIR/ADDITION I I OEgRUCTION _(No septic system permitted l public er is available within 200 Ie t �; Installation will serve: Residence Commercial— Other `" � y� lap— ert- N Number of living units: Number of bear oma ig F,� lj_ m;fi ..4'rL Character of soil to a depth of 3 feet: W ter table depth _ SEPTIC TANK. )E( Type/Mfg Z Capacity. /LUC/ No. Compartments PKG. TREATMENT PLT. ❑ f Method of Disposal i Distance to nearest: Well J�l� Foundation property Line �7S_� LEACHING LINE No. & Length of lines i� Total length/size 71) �>� FILTER BED ❑ Distance to nearest: Wit-s7-«— Foundation d Property Line AQ,_,,,___ SEEPAG PITS 11 Depth Size 2- Number- . � SUMPS l l Distance to nearest: Well,_A26 Foundation— Property Line_/2 DISPOSAL PONDS 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: "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 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 California." The applic fo it i specti s. mplete drawing on ever a side, " Signed Title: Date: � FOR DEPARTMENT USE ONLY ,q Application Accepted by Date `Y` � 1 Area Z Pit Grout Inspection by �^ at l�Final Inspection by Date 1_&_"1_1 Additional Comments: .10 Applicant - Return all copies to: San Joaquin County Public Health � X ' Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201FEE 7 INFO (AMOUNT DUE AMOUNT REMITTEO CASH CK RECEIVED BY /DATE PERMI7'N0. a EH 13-24(REV.1)A5) / Awl ` C1 EH 14-2a l � 7 �J