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T � t APPLICATION FOR PERMIT � c SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES rI I ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)4$8-3420 P O BOX 2009, STOCKTON, CA 95201 PWRMSP RES 1 YEAR FROM DATE J'! (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. i Job Address brja�a 1 City 1 Lot Size/Acreage ...�— •� �"��- Address � Phone -- al Owner's Name i Contractorof ser ice well L) /� "t Address License No.yS�.--��--Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out Monitoring Well l PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER lit 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 L7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Type Specifications &Domestic/Private ❑ Gravel Pack T❑ Tracy Yp of Casing Type of Grout VI Public CI Other I� P Delta Depth of Grout Seal I I Irrioation _..Approx.Il'Depth I I Eastern Surface Seal Installed by � r H.P. I _ Stat Work Dc e Repair Work Done 4t Type of PumpLyfj tt -Well Destruction ❑ Well Diameter' Sealing Material & Depth Depth _ - '.Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I'1 REPAIRIADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 leet.i Installation will serve: Residence— Commercial Other ab,,. Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth ,, No. Compartments SEPTIC TANK- © Type/Mfg� ��" � 4� f ` 'Capacity No. _- Method of Disposal _.e t i PKG. TREATMENT PLT. ❑ , t f-A ; Distance to nearest: Well :`Foundation ^ Property Line £ f Total length/size r ' LEACHING LINE ❑ No. & Length of lines f w. FILTER BED [] Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1_1 Depth Sire .} Number Y SUMPS k Distance to nearest: Well Foundation r t Property Line w DISPOSAL PONDS ❑ that the work will be done in accordance with San Joaquin county ordinances, state laws, and I hereby certify that I have prepared this application 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 subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ person subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. j Signed XTitle: . N^[.`'' _Date: R/2-!' a — F DEPARTMENT USE ONLY Application Accepted by Data l/��r � A a ` Pit or Grout Inspection by ate - Final Inspection by Date��o i Additional Comments: Applicant - Return all copies tot: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 i FEE AMOUNT DUE + AMOUNT REMITTED CCK C RECEIVED BY PATE PERMIT NO. INFO {�1 �• 0 , EH 131 4 MEV.1 i n 51 EH i!-T6