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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 >al'iRM i T W I RES 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 1$62 and the Rules and Regulations of San Joaquin CountyPublicHealth Services. Job Address —U > C-/Ue QZSK cl City Lot Size/Acreage Owner's Name �` �L`.1 1 f I�� AddressG� _— Phone Contractor . L JCSAddress . p ''4� Od+7 License No. ;�Phone ' Zz�1? TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 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 Ll Industrial ❑ Open Bottom '❑ Manteca Ria. of Well Excavation - Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack Ll Tracy Type of Casing Specifications I'1 Public : Cl Other Ll Delta Depth of Grout Seal �° Type of Grout I I Irfigation _.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L3 Type of Pump r H.P. State Work.Done_ Well Destruction ❑ Well Diameter Sealing Material b Depth Depth Filler Material iG Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION I )ANo septic system permitted if public sewer is available within 200 feat.l 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 Capacity No. Compartments PKG. TREATMENT ALT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines Total length/size ' FILTER BED ❑ Distance to nearest: Well IC� 104" Foundation 24, r Property Line _ ID 4 D [� elf SEEPAGE PITS Irl Depth S� Size 7�T Number SUMPS Cl Distance to nearest: Well Z:W Foundation � Property Line 'Zr 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, 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 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 call for all required inspections. Complete drawing on reverse side. ff �a �i Signed X K fit_.:.+, Title: �.� �" Data: `` R DEPARTMENT USE ONLY Application Accepted by ��r , - AA. a,� Date -air C7 Are, ,. Pkf,E>fjGrou!Inspection by1V1 �� Dat Z _` U_ Final Inspection by 1 O - Data Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 S. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 INFO AFEEMOUNT DUE AMOUNT REMITTED CASH K f RECEIVED BY DATE! PERMIT NO• VV . EH13'241REV.I�K5] EH 94-20