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,APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZRLTON AVE. , PHONE (209)468-3424 P O BOX 2009, STOCKTON, CA 95201 PERUm EXPIRES 1 YEAR FROM DATE IS (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 1852 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address �;U (5_ WF City`�� k Lot Size/Acreage ee Owner's Name c�ac J C/ Address T��Vr e Phone Contractor,L,'r � 'r'"= Address`we '� C � License No`' Fyp6 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT LJDESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 91, INTENDED USE- TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C] industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing .C.1 Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public 1-1 Other n Delta Depth of Grout Seal Type of Grout I I Inigatior" —Approx. Oepth I I Eastern Surface Seal Installed by r t, Repair Work Done U Type of Pump H.P. State Work Done 1 Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION K REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sower is ' available within 200 feet.I Installation will serve: Residence 91 Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: �`' ® 8 Water table depth SEPTIC TANK Type/Mfg e:?OA C'P Capacity a0d No. Compartments PKG. TREATMENT PLT. ❑ • Method of Disposal/.CWC sa Distance to nearest: Well/" Foundation Property Line 1AQ ' length/sizeC ' /Ry•r + O LEACHING LINE (,$� No. & Length of lines �,3! OR y6 Total rO FILTER BED O Distance to nearest: Well /v`` Foundation .,.�4 _ Property Line ,._ � i SEEPAGE PITS Depth Size M& Number /9#0 r � i SUMPS Ll Distance to nearest: Well�#�� Foundation �'� Property Line /U V yy DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and ` rules and regulations of the San Joaquin county Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant Mp#t ca/ll for all requirgg ins pe tions. Complete drawing on reverse side, [ / Signed _,I , Title: �//'G.fI�C'f1- Date: + l� ffA&TMOT USE ONLY II Application Accepted by + Date y ea Pit or Grout Inspection by Date Final Inspection by.. Data Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT�NO. INFO CASH . EH 13.24 IREV.I/H si // �($ EH 11.2E +� COV f 00W