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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I ENVIRONMENTAL HEALTH DIVISION "1601 E. HAZELTON AVE. , PHONE (209)468--3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATES ISSUED (Complete is Triplicate) Application is hereby made to Seen Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. 14A (tow west-Side'OfJob Address 0cm Q' Sc, City._IAJ I. Lot Size/Acreage Owner's Name 4/flo~ `�L_ Address + V"r y t` j C4 `�2 � PhontVI g� -04IZt "'4" �t"Ly erA� sad ` Cantractori�lll�G'L�`R{ Address � LOr_ d�fL- �1�b70 License No. '4 Phon �b 'V-7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION AOut of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing N Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Il Public t-1 Other } f-1 Delta Depth of Grout Seal Type of Grout ,[ I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pumpf WP. tate Work Done r II Well Destruction 16, Well Diameter -C f, Sealing Material & Depth . ismoto,(,. CMt/h -0 'ItccT Depth 11Y± Piller Material & Depth As_ TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIR/ADDITION I E DESTRUCTION 1 1 INo septic system permitted if public sewer is available within 200 feet.) i Installation wilt 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. ❑ i Method of Disposal Distance fD nearest: Well Foundation Property Line LEACHING LINE Ll No. & Length of lines Total length/size FILTER BED Cl Distance tri nearest: Well Foundation Property Line t SEEPAGE PITS 11 Depth Size Number SUMPS tl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I I hereby certify that ! 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 cenifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any personin such manner as to become subject to workmen'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, t shall employ persons subject to workman's Compensa- tion laws of California." The applican must {��{ I! ft�alluiredinspections. Complete drawing on reverse side. IF Signed )C__ c[ IFrrr1 f - Title:6el IMA b46 Vr &ry" Date: 7h_ FOR DEPARTMENT USE ONLY p,4) tlor � ,y Application Accepted by �l (� Date Z Z Area 4-, y►~7. `II_ Pit or Grout Inspection by Data + I Fine) Inspection by Date r i -7 Z Additional Comments: 1 1 Applicant - Return all copies to: Sas Joaquin County Public Health Services, Environmental Health Permit/Services 1601 S. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED /CASH CK 4 RECEIVED BY DATE PERMt7'N0, EH 17.24 1REV.riw51 �i y Ad qZ