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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 0 BOX 2009, STOCKTON, CA 95201 kEMIT 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 �Serv(iicc(e'�s'. �j � , Job Address � ]_ Zff l�/_- 1_S_>�1s_Y1 �Z �c( City l 92/T� - Lot Size/Acreage 5 0cY a m c Owner's Namede� izo ddressl3&t17.M hG j�1 t>CteKona T ` Contractor t/GF r Address l Q vZ ?T_ License No- WF- Phone -a TYPE OF WELL/PUMP: NEW WELLAC WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well 0 PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK S`d SEWER LINES DISPOSAL FLD. PROP. LINE c!�O_.�,'n. FOUNDATION AGRICULTURE WELLS OTHER WELL PITS/SUMPS,.3-W " INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO S 1i. F1 Industrial ❑ Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing ."Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing `��ef. Specifications /D I'1 Public Cl Other F-I Delta Depth of Grout Seal Type of Groutl �_41Gc�_ I i Irrigation Z—_PAppfox. Depth I 1 Eastern Surface Seal Installed by��f _,✓ _ �r/1 Repair Work Done ❑ Type of Pump IS C.2 H.P. -;;)- State Work Done — Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth (Vn TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is "1 available within 200 feet.I 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 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 length/size FILTER BED 1=1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size T Number SUMPS LI Distance to nearest: Well Foundation Property Line 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 applicant must call for all required inspections. Complete drawing on reverse side. AF/i Signe Title: t Date- R DEPARTMENT USE ONLY rr Applicatio ccepted by C-.)AC-IAt, �.� Data �! � �� Area Pit orCrouCtIns ction byDate Final Inspection bAdditiomments: 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 FEE INFO OUNT pUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO, EH 13-24(REV.11 N 5) EH.26 DJ�� 7