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APPLICATION FOR PERMIT ' SAN JOAQUIN. COUNTY PUBLIC HEALTH SERVICES • .r ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVEi, PHONE (209)458-3420 a + P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES- 1-YEARFROM DATE 1h5!5URD (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 Servi es. [j(� Q Dj-a f � i ]nn 90 Ac Job Address P 1 084 03-03 �� '� & City Lot Size/Acreage N baba Q�ets�l �5�10� Owner's Name ! fl Y1R(� Address ! • 11 Phone Contractor Address S License No.�[�� Phoned : 1 r� TYPE OF WELL/PUMP: NEW WELL D WELL,REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ r ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER �(CTeII5Mo torn Well DISTANCE TO NEAREST: SEPTIC TANK --SEWER-LINES--- PROP.�DISPOSAC`FLD." PROP. LINE t FOUNDATION I AGRICULTURE WELL)SlOTHER WELL PITS/SUMPS INTENDED USE TYPE OF,WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �r C-) Industrial I3 Open Bottom 0 Manteca Dia. of Well Excavation Oia. of Well Casing * Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications U1 Public CI Other i 171 Delta Depth of Grout Seal _ 1�r Type of Grout I I Irrigation .Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. x State Work Done Well Destruction ❑ Well Diameter ESealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION [ I DESTRUCTION I I (No septic system perrriitted if public sewer is It I available within 200 feet.) Installation will serve: Residence__ Commercial— Other (� Number of living units:' Number of bedrooms (1 Character of soil to a depth of 3\feet: 1 Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. D Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED I1 Distance to nearest Welt Foundation Property Line L f SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 ' 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 r Home owner or licensed agent's signature certifies the following: "I certify that in-the performance of the work for which thita 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 fol',, I required inspections. Complete drawing on reverse side. Ohl Signed X „,..,._ Title:11' Sr �!h / Date: K J�r � x FOR DEPARTMENT USE ONLY n Application Accepted by MALt Date ` an Pit or Grout Inspection VY D to Final Inspection by Date Additional Comments:, C-b c Applicant - Return all copies to: San Joaquin Lunty Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave.. P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. EH 13.24 MEV.I/n51 C OrJ I�f /yam 2 EH A. � 1 !� � � ( O a 1�S 1