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i APPLICATION FOR PERMIT I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES i ENVIRONMENTAL HEALTH DIVISION 3.601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 I ' MIMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to Saiz 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 C L��'- Cit Lot Size/Acreage Owner's Name tAV L T- �� ti I Address A ft&�2 Phone /� s✓ Contractor Address0JC'Ka�J� ( License Na_?i�r �63 Phone v[a 7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ k PUMP INSTALLATION O SYSTEM REPAIR') OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLU, PROP. LINE FOUNDATION AGRICULTURE WELL+ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 6 Domestic/Private ❑ Gravel Pack- ❑ Tracy Type of Casing Specifications I'] Public Cl Other 'n Delta Depth of Grout Seal Type of Grout I i Irrigation �.Approx. 'Depth- I I Eastern Surface Seal Installed by Repair Work Done `l" Type of Pump H.P. 7�� State Work Done Well Destruction ❑ Well Diameter Sealing Material;& Depth Depth f' Filler Material & Depth /d l TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ( I DESTRUCTION I I (No septic system permitted if public sewer is , available within 200 feet,) Installation will serve: Residence I, Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet,t# Water table depth 1 SEPTIC TANK. ❑ Type/Mfg'' Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to`nearest: Well foundation Property Line i LEACHING LINE 0 No. & Length of lines � � Total length/sire FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation property Line DISPOSAL PONDS Cl M , r I hereby certify that I have prepared this application and that the work will be'done in accordance with$an 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 cartifies 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." r The applicantIi for all required ins ctions. mplete drawing on v rse Aide. i Signed Title: Date: R DEPARTMENT USE ONLY I Application Accepted by Date _d;�PP Area Pit or Grout Inspection by Date Final Inspection by\ -�fV� Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Eavironmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 I ffIFEE AMOUNT DUE AMOUNT REMITTED CABFI RECEIVED BY yyD11ATE PERMIT'NO. E EM t3-241REV.riHsi U/R ` ,Q� Zig -M t 1 yt �� EM I ii ��[[ �3 j/ r 1 4