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PM APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1.601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIpR��ES 1 YEAR FFpROED �M DATE ISS-UM b�e+�[A� lf" I �li cafe) 30� 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 1862 and the Rules and Regulations of San Joaquin County Public Health Services. pP� 7—-z, Q fo 0 0 r '/b �.. Job Address �� - /, /"lA� -S City AVG Lot Size/Acreage � � /qr re/U4�� `�� - _ Phone 9 Z_ Owner's Name �tl.arlr�d*7` ,GPf-� _ Contractor . = � address �8 LryP7� License No. z� Phone 0-131 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER M or $-e, r,,4:S7- e/rt DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONSF /.v F] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation �stin Cl Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Speeft tfens 404, GFf I"I Public 1-1 Other Cl Delta Depth of Grout Seal grout 'l —'7 r 1 1 Irrigation T Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction O Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION ( 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 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 1J� PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Ll No. & Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS I [ Depth Size _ Number SUMPS LI 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, 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 muN call for all r ed inspections. Complete drawing on reverse side. / Signed X Title: Date: Li FOR EPARTMENT USE ONLY Application Accepted by Date - a Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: a 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 INFO AMO`U1 NT DUE AMOUNT REMITK H RECEIVED BY DATE PERM17'NO. . EH c7t-26 3-25[REV.t i n s) EH 2{"1 t(3D0 1 7