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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 SOX 2009, STOCKTON, CA 95201 PFaMTT 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 tate 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 Address 50/ tt& City Lot Size/Acreage PO P-a--x 58 Owner's Named Address a-k� 9y�p 3 Phone /�57l`-� 3 Wayne I �}� 4 C �» � �t Contractor ne f-�' f if j Address 'd 'n 7�� I 1 p M 9 Ocense No.3 7(13yS Phone '9b3r-g35'y� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C] DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR G \(fW0&W1aLOTHER 14 Monitoring Well f] DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 2-5" DISPOSAL FLO. IVA_ PROP. LINE b5� FOUNDATION 'S� AGRICULTURE WELL LYt+ OTHER WELL aOO' PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 10,11 Dia. of Well Casing " CI Domestic/Private .Gravel Pack L7 Tracy Type of Casing Specifications Il Public fa Other ❑ Delta Depth of Grout Seal R Type of Grout -nkrtAd - I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by_ ---�� -.-- Repair Work Done ❑ Type of Pump H.P. State Work Done Weil Destruction ❑ Weil Diameter Jai Sealing Material & Depth \ Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I Z INo septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soli to a depth of 3 feet: Water table depth +� SEPTIC TANK ❑ Typa/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 C7 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 fallowing: "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 ust call for all re uir d inspeCt'ans. Complete drawing on reverse side. Signed Title: _ _ Date: f C- RS d/t �, �,/„�ij /�� FOR DEPARTMENT USE ONLY Application Accepted by Date Area 3 Pit orrout nspection by Date Z Final Inspection by Date Additional Comments: 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 AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EN 13-24 IiIEV.t i M 51 �e Y EH 14.26