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APPLICATION FOR PERMIT SAN jOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAI;' HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 ! EXP RES 1 YE R FtOM DATE (Complete in Triplicate) Thitall vork in Application is made in compliance liance with BanCounty Joaquinor a permit county ordinancenstruct No. 549aando1862sand theeRules andeRegulationsdof Sans application is made otap Joaquin county Public Health Services. Go/. Lot Size/Acreage G2� v City.�..k�— , 6 Job Address t 90 7J�lry �G�a Phone _ Address Owner's Name r ' CTL'icense No. -- Phone Contractor_� Address we NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Wel! ❑ TYPE OF WELLIPUMP: OTHER ❑ Monitoring Well PUMP INSTALLATION ❑ SYSTEM REPAIR G7 SEWER LINES _..�.�.�---- DISPOSAL FLO. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK �-- OTHER WELL PITSISUMPS FOUNDATION _ AGRICULTURE WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Type of Casing Specifications t:l DomesticIprivate ❑ Gravel Pack £] Tracy YP Type of Grout I"I Public I- Other n Delta Depth of Grout Seal i I Irrigation _Approx. Depth ' I I Eastern Surface Seal Installed by of Pump's--- H.P. State Work Done i Repair Work Done U Type Sealing Material & Depth `. Well Destruction ❑ Well Diameter Biller Material & Depth b Depth , pp� i TYPE OF-SEPTIC WORK: NEW INSTALLATION Jk REPAIR/ADDITION i I DESTRUCTION l I (Nosystem septrwit in 200 feStit'ed if public sewer is Cl I f III Installation will serve: Residence! Commercial Other Number of bedrooms !� f r Number of living units: � J"rt"" i Water table depth 1� Character of soil to a;depth of 3 feei:y ! No. Compartments J Capacity F SEPTIC TANK ❑ Type/Mfg! r` Method of Disposal PKG. TREATMENT PLT. ❑ �.� ,,. - i �` 1b'f^ Property Line 3O Distancefto nearest: Well Foundation 1Z17V-2r i 1 Total length/size LEACHING LINE 0 No. & Length of lines - s i -4k.. 1 Foundation I �— Property Line�� FILTER HED ❑ Distance to nearest: Well- ' Flo � SEEPAGE PITS I k Depth aS Size s Nymbar 3 SUMPS LI Distance to nearest: Well Foundation �,r�--�- Property Line_ DISPOSAL PONDS 1 0 1 I " thereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and t rules and regulations of the San Joaquin icounty / I " fy that in the performance of the work for which this permit is issued, I shalt/ at(' Home owner or licensed agent's signature certifies the folio • wing: certify 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 cal r all re red inspections. Co plat djrawing on reverse side. l Q } / Title: Signed X Date: + a F &RARTMENT USE ONLY yy 1 •- ,,,,p.,. ""'"' t ~ ao Area Date Application Accepted by t Date Final Inspection by Data Pit or Grout Inspection by Additional Comments: t Applicant - Return all copies to: n Joaquin CountyP Sam blic HealtServices, Environmenta.1 Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 CK RECEIVED BY DATE PERMIT'NO. I � FEE OUNT DUE AMOUNT REMITTED GASH ( h INF a EH1324 IREV. /n 5i EH 14.26