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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 BOX 2009, STOCKTON, CA 95201 MMIT 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 4eZ>1 Lot Size/Acreage C.. Owner's Name - 1�5� � �lO. t7 Address Phone Conlraclor 4.0 cV,0 -Address-.-2 AA .i ,L�4 iii License No.-,V-2ff y7Z Phone -39 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 FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing N Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I') Public n 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 LJ Type of Pump H.P. State Work Dona Well Destruction O Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK; NEW INSTALLATION XfREPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is ) available within 200 feet.) Installation will 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 - { �'L- . ... Capacity—d!!!��e No. Compartments F PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well /'Lle Foundation i Property Line /O- ' LEACHING LINE No. & Length of lines __ -- 40,9 . Total length/size Q ` FILTER BED ❑ Distance to nearest. Well.-ZVI�P Foundation_ � f Property Line SEEPAGE PITS Depth .-L Size 2- Number SUMPS Ll Distance to nearest: Well��Foundation Are _ Property Line�11+2�r-YjQd DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an 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 following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: Data: Z- FOR DEPARTMENT USE ONLY Application Accepted by �' �,�1 Date? �-,�d.r�� Area <91 or Grout Inspection by �"D`aTe -7-��-�_2.-Final Inspection by7-l� ,.1 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 CK INFO d MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMITNO. ( DD GK / . EH 3-24(REV.I/x 5) 010N- 3 EH t4-2a ZLhL- 1