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APPLICATION FOR PERMIT a SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOR 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FR M DATE ISPUED (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. If _YkCity Lot Size/Acreage Z� Job Address S Owner's Name Contractor IA]t �i_� � Address��7�`�1 -�f C 6 S"+ . License No. Phone 1 TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT [i DESTRUCTION Ll Out of Service Well ❑ c 1 _ ._. A— ....t....T�-_....-.-T _ _ . -- ---� --^---�- �• -- - � Monitoring Well �� PUMP INSTALLATION ❑ SYSTEM REPAIR L OTHER ❑ I 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 �. -F) industrial -"""""''-"❑ Open B6tt6M--—I11-Manteca"__ ' 'Dia. of Well Excavation Dia:-6f Well Casing"" N Domestic/Private ❑ Gravel Pack C7 Tracy Type of Casing Specifications V1 Public 1-1 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 U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth Depth f Filler Material &'Depth TYPE OF SEPTIC WORK: NEW INSTALLATION EPAIR/ADDITION l I DESTRUCTION i I (No-septic-system permitted if public sower is �- i available within 200 feet.1 Installation will serve: Resid�jnce y�Commercial- —Other -A Number of living units: __�_L Number of bedro s Character of sail to a depth of 3 feet: ET v Water table depth � ' X No. CompaenSEPTIC TANKFj �ype/Mfg Ca ts PKG. TREATMENT PLT. ❑ tk ;; q Method of Disposal Distance to nearest: Well F9undation Property Line —iA � LEACHING LINE C4�'is& Length of lines T�tal fengthlsize FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS f I Depth Size € Number SUMPS L4--13istance to nearest: / Well Foundation Property Lina DISPOSAL PONDS ❑ j I Hereby certify that I have prepared this application and that the work will be done in accordance with San'Joiquin 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." n 9 '� The applicant st Il for all�req rred i specti ns: Iste drawing on v verse side. Signed \l / �J Title: Date: r FOR DEPARTMENT USE ONLY Application Accepted by 4- 'Q Date `' — Area Pit or Grout Inspection by Date " Final Inspection by f Date G/ 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 -AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT•NO. INFO + EH 13-241REV.1)NW 3 7- q .91 i! EH 14-2E IN 0_�' 1losrl - 1.