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APPLICATION FOR PERMIT J7 /" L SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOR 2009, STOCKTON, CA 95201 PRRL(TT EgPIRES 1 YEAR FROM DATE UD (Complete in Triplicate) Application is hereby made,to San Joaquin County for a permit to constru t a or install the Work herein described. This application is made in compliance with San Joaquin County Ordinance No. 5_+9 an 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Addres Q City- 5 a Lot Size/Acreage 10 ig - Owner's Name Address z S — Phone 8- r f 5t�( /) y -03� Contractor�� II Address da V License Ivo, 4 Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT C_l DESTRUCTION ❑ Out of Service Well ❑ i PUMP INSTALLATION- SYSTEM REPAIR ❑ /�O�TIJER 71 Monitoring Well €] DISTANCE TO NEAREST: SEPTIC TANK r- EWER LINES DISPOSAL FLD/90- PROP. LINEflS Il FOUNDATION AGRICULTURE WELL OTHER WELLPITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS- .r' Cl Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing W I 4.DomesticlPrivate -Gravel Pack 0 Tracy Type of Casing .�� Specifications O F I 1'I Public f thea n Delta Depth of.Grout Seal f Type of Grout &O hill f I I Irrigation drZApprox. Depth 1 I Eastern Surface Seal Installed by Repair Work Done U Type of Pump �,JJJ2M- H.P, 2- State Work Hone _ Well Destruction El Well Diameter Sealing Material & Depth Depth ^� C7 Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION•1 I DESTRUCTION i I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms I Character of soil to a depth of 3 feet: Water table depth r f SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Ll No. & Length of lines Total iength/size FILTER BED Distance to nearest. Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Cl 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 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 j 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 u t call far all required-ins c ions: Complete d awing on (averse side, _.a Signed X Title: Date: —t� = FOR DEPARTMENT USE ONLY ; ApplicpmrrA,ccepted by w Date Pit r Grout spection by Date Final sp ction by Date Additional Comments: Applicant - Return all pies to: SanJp gain County Public alth Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK N RECEIVED BY DATE PERMIT'NO. INFO //��.t CASH r ` . EN 13-24 IRE,,,, 131 -a� ,L/4 , ct �� t I EH 14.2E