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APPLICATION FOR PERMIT I � SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES + I ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 EXP RES 1 YEAR FROM DA E (Complete in Triplicate) Application 1s hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance;irith San Joaquin County 0 inance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. /yv'�` S.J. �I"�J �10 I r City � .127 Lot Size/Acreage g2_ - .lob Address b[J / Address Phone Owner's Name 74;z / P .5W3 Y /,. 4A License No.CS-2s 24 Phone Contractor Address --1 TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION L) uut of Service well ❑ OTHER Monitoring Well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ /06,-,,7j DISTANCE TO NEAREST: SEPTIC TANK /l1YIt' /IPa'+ SEWER LINES DISPOSAL FLO��OP. UNE l e. FOUNDATION �«AGRICULTURE WELL v � 7HER WELL_ �!T�� PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing �—,� C7 Industrial ❑ Open Bottom Manteca Dia. of Well Excavation Specifications Domestic/Private 0Gravel Pack C] TType of Casing racy 3 Type of Grout i"1 Public t-1 Other x fl Delta Depth of Grout Seal , 111fdoation 1�5Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump_ H.P. State Work Done , Well Destruction ❑ Well Diameter' Sealing Material & Depth Depth A Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDe ITION I ! DESTRUCTION l I availabtrwi system within 200 fe;it�ed if public sewer is Installation will serve:' Residence—• Commercial— Other— Number ther—Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. C3Type/Mfg No. Compartments 1 Method of Disposal PKG. TREATMENT PLT. 0 1 t Distance to nearest: Well Foundation' Property Lina . LEACHING LINE ❑ No. & Length of lines **�� Total fengthlsize FILTER BED Cl Distance Ito nearest., Well JUN d ri Property Line i1 SEEPAGE PITS I I depth rl -Size�jONMEhT�� Number � i�U�T tion— Property Line 4SUMPS L l Distance to nearest: Well 11 DISPOSAL PONDS 0 t - 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 I 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 applicants must call for all required inspections. Complete drawing on reverse side. Signed X / T'"""� — Title: pate: FOR DEPARTMENT USE ONLY f Application Accepted by Date ^� w Area f ate Final Inspection by Date ` Pit or Grout Inspection by `!. Additional Comments: I `� i §. Applicant – Return all copies to: San Joaquin County Public Health l} Services, Environmental Health Permit/Services 11 1601 E.'Hazeltoa Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO /�''� e�siv�p W-,- EH �� J _ f (� " EH 13-24 SREv.tixsi 00 f♦ �� J 1 r k� �!J' l�•—L1.: EH#4.26 V