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&t _gy.. APPLICATION FOR PERMIT �d4'"- ISAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 i P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXP RES 1 YEAR FROM DATE QED t Vis© r4P_d1C 4� � ; (Complete in Triplicate) 21-3 p-la_�r Application is hereby made,to Sao 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 f Joaquin County Public Health Services. p � 21N4- Ll /+'{� IJ C AY I.} I�,%, � City Lot Size/Acreage , �ob Address },,� t wner's Name G'`"`� � Address Phone K:h Contractor Address t License No.S { Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT E1 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER .1 +Moni�ring Well ❑ So,L ot DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS y r INTENDED USE TYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing fl Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications VI Public F1 Other * Cl Delta Depth of Grout Seal Type of Grout 1 1 Irrigation Approx. Depth t I Eastern Surface Seal installed by !( Repair Work Done U Type of Pump H.P. State Work ne Well Destruction ❑ Well Diameter Sealing Material & Depth V }) r Depth Filler Material d Depth k TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION t I DESTRUCTION I I INo septic system permitted it public sewer is available within 200 feet.1 V.' installation will serve: Residence Commercial_____ Other • a , 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 f PKG. TREATMENT PLT. ❑ 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 Foundation Property Line SEEPAGE PITS 1 1 Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line 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, an 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 no employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signatur 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 an reverse side. / Signed X TiNe: Cyt b 7�e cAo (i a "I Date: FOR EPARTMENT USE ONLY f r Application Accepted by drg Date U Area.— / k Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health i Services, Environmental Health Permit/Services tl 1601 E. Razel.ton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH r EH 6-24(REV.7/x 5) U-D L J - O-D 7�00 7-1710 qv- W }�. E4`1%-X