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r APPLICATION FOR PERMIT SAN JOAQUiN COUNTY PUBLIC HEALTH SERVICES I 1 ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 [[[ P O BOR 2009, STOCkTON, CA 95201 . PMRMIT EXPIRES 1 YEAR FROM DAIN ISSUED (Complete in Triplicate) Application is'here made to San `Joa uin Count for i?p by q y permit to construct and/or install'the work herein described. This application is made in compliances'rith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Hea/ltth Serrvices. L _ f f - Job Address _S )1.117 I5 : `0,SG 7�J5 City �1 L� Lot Size/Acreage Ifa AG, Owner's Name E S 114 , +GC,J Address v`1� nl _! t YLe----lG - --- — Phone 'X33 g Contractor f fQ ! Address mf— License No. Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEf�1ENT ❑ DESTRUCTION ❑ out of Service Well Cl PUMP INSTALLATION ❑ SYSTE REPAIR ❑ OTHER ❑ Monitoring Well U { DISTANCE TO NEAREST: SEPTIC TANK WER LINES DISPOSAL FLD."x PROP. UNE T FOUNDATION AG CULTURE ELL OTHER WELL PITS/SUMPS- INTENDED ITS/SUMPSINTENDED USE TYPE OF WELL PROBLEM AR ONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 11 Domestic/Private ❑ Gravel Pack! ❑ Tracy Type of Casing Specifications ~ i'1 Public Cl Other n Delta D th of Grout Seal Type of Grout l I ) Irrigation Approx. Depth I I Easte Su a Seal installed by Repair Work Done L3 Type of Pump H.P. State Work Done _ G Well Destruction ❑ Well Diameter Sealing Ftateria !lk Depth Depth ? Filler Material A th C TYPE OF SEPTIC WORK: NEW INSTALLATION 4'l REPAIR/ADDITION I f DESTRUCTION I I INo septic system permitted if public sewer is F 1 available within 200 feet.) r installation will serve: Re idence�1Commerciaf— Other Number of living units: Number of edrooms Character of soil to a depth of 3 feet: _ Water table depth `1 SEPTIC TANK. Ja Type/Mfg —L Capacity No. Compartments �. PKG. TREATMENT PLT. ❑ t Method of Disposal Distance to nearest: Welli��2 Foundation Property Line,--.Io 1 ' LEACHING LINE 0 No. & Length of lines "q Total length/size IC90 FILTER BED L) Distance to nearest. Well Foundation ,LS.L— Property Line !<tD SEEPAGE PITS 11 Depth .2 Size. - Y Number 32 SUMPS LI Distance to nearest: Well ?Z Foundation /CJ Property Line DISPOSAL PONDS ❑ I ,- 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 son in suc a to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature Certifies the f I wing: , ertify th the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of a'fornia.' 7 The applica t ust C at quit inspections. Complete drawing on reverse side. t Q Signed Title: W h C Date: EPARTMENT USE O Y Application Accepted by Date Pit or Grout Inspection by Date f=inal Inspection by Date Additional Comments: Applicant — Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 16011 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK I GASH RECEIVED BY DATE PERMIVND. r EH t3-2�IrtEV.1/H51 1 I�r ow �, , it........... [ M O �Z�-2o g t EH Z4-A 1