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h APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM D E ISSUED (Complete in Triplicate) Application is hereby made.to San;Joaquin County for"a permit to construct and/or install the cork herein described. This application is made in compliancelvith San Joaquin County Ordinance No. 50 and 1862 and the Rules and Regulations of San Joaquin County Public H alth Services. Job Address TU AA City -S Lot Size/Acreage Owner's Name `�fJC1 J/ rAddress ��rn Phone Contractor IlVTTh �,� dAddress License No. 2=2 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE"- FOUNDATION AGRICULTURE WELL OTHER WELLS-_- PITS/SUMPS".. ___ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS"" _ fi Ll Industrial ❑Open Botlom C1 Manteca Dia, of-Well""Excavation Dia. of Well Casing Ca Domestic/Private .❑ Gravel Packer ❑Tracy' T Type of Casing Specifications V1 Public Cl Other 1 fl Delta Depth of Grout Seal Type of Grout 0 I I Irrigation _Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done 0 Type ol,Pump1 H.P. State Work Done T I Well Destruction ❑ Well Diameter, Sealing Material 6 Depth Depth jiller Mat Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I__REPAIR/A DDI ION ! STRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_i Commercial Ser Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: I Water table depth SEPTIC TANK ❑ Type/Mfg { Capacity No. Compartments PKG. TREATMENT PLT. ❑ . I - ' Method of Disposal _ Distance to nearest: Well-1/9 0 _ Foundation a _ Property Line LEACHING LINE [�-�o. & Length of lines Total length/site FILTER BED ❑ Distance toYnearest: Well Foundation 4 � � ,� Property Lina�� SEEPAGE PITS N—Depth �f�5 -Si a N�ember SUMPS LI Distance to nearest: Well.� _ Foundations Property Line DISPOSAL PONDS ❑ 11 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 fallowing: "I certify that in theperformance 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- tio aw alifomia T applicant m all for a r uired in pe do S. o e-drawing-on-reverse ide.--. �_ Signe Title: 7 Date: _ � FO MfNT_USE_ONLY f Application Accepted by Dare Area Pit or Grout Inspection by Data Final Inspection by - Date r Y Ld F� Additional Comments: - Applicant - Return "all copies to: Il Ban Joaquin County Public Health ----�- --^------�--- }Bervi•ces;Envi-ronmenta.3.-Realth-Permit/Services ,-�----�^ t•'^— ; 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201FEE v INFO AMOUNT DUE AMOUNT REMITTED CK 9 CASH RECEIVED BY DATE PERMIT'NO, s a EH 1124 IREV.1in51 j r ! Yn , �� tj231,- 6 ..3U Q l