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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1 ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 ' P O BOR 2009, STOCKTON, CA 95201 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 Services. Job Address City 7 Lot Size/Acreage Owner's Name VIM =%WA(6ddr. Phone Conlraclor/A.A UI)9L C- Address ' CL ense No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C1 Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia- of Well Casing Cl Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications I') Public C1 Other Cl Delta Depth of Grout Seal Type of Grout I # Irrigation �.Approx. Depth 11 Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction D Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ( I DESTRUCTION eptic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence ommercial_ Other Number of living units: Number of bedrooms CP 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 Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS l_I Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work wilt 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 person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature ce ' ' 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 alifornia1by ' The app ca m caV!ele drawing o reverse ,'de, Sig ills: Date. r SE ONLYApplication Accepted Date Area Pit or Grout Inspection by Date Final Inspection by Date C 6 �� 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 pUlc AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. r EH13-21tREV.i/n51 V r� ab �0�93 EH 94.25