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d s APPLICATION FOR PERMIT 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 PERMIT t ' EXPIRES1 XEAR__FROM D E ISSUED (Complete in Triplickte) I Application As 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 Se(r�v]i"ce`s. ` W f Job Address I', N0 City Lot Size/Acreage Owner's NamegddressPho �' ne Contractor=� \r'tAddress O V� ](L4-) V<_ License No. Phone TYPE OF WELL/PUMP: NEW WELL Cl WELLREPLACEMENT F_1 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION'"❑ �e\ SYSTEM REPAIR C1 OTHER C1 Monitoring Well C]DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f 7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Fl Domestic/Private ❑ Gravel Pack .. L1 Tracy Type of Casing Specifications 11 Public 1-1 Other Fl Delta Depth of Grout Seal Type of Grout I I irrigation — Approx.`Depth 13 Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done R s Well Destruction ❑ Well Diameter Sealing Material & Depth Depth { Filler Material & Depth i TYPE OF SEPTIC WORK: NEW INSTALLATION [if REPAIR/ADDITION [ I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation wilt serve: „Residence_!nlCommercial; ?ther Number of living units: �� Number of bedrooms t Character of soil to a depth of 3 feet: 'Water table.depth; SEPTIC TANK, [YIYT s/Mf t " q Yp 9 �" Capacity__ U No. Compal marcid PKG. TREATMENT PLT. ❑ 4 Y t ` Method of Disposal Distance to nee'rist: "Well QC7 L} lsI �a� Foundation �� Property Line LEACHING LINE No, 8 Length of lines r r' ,Total length/size 9 FILTER BED Cl' Distance to nearest: Well 2kC16 — Foundation _ 1 il't: x Property Line-2t] f i kx. _ _ { SEEPAGE PITS t 1 I Depth I I Size Number SUMPS L) Distance tol nearest: Well Foundation G Property Line DISPOSAL PONDS p 1, ; 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 k,,. µ 111, Home owner or lic used agent's signature.certifies the following: "I certify-that in the performance"of the work for which this permit is it ssued, I shall not employ any person in such manner as to become subject to workman's compensation laws of Caii*nia." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the'perfor ante of the work for which this perMitis issued,.)sh all employ persons subject to workman's compensa- tion laws of Callf6mla." ry The applicant mu/101 for all requ inspecti ns. Complete drawing on reverse side. y ? Signed Title: -t Date: S 17Z 17Citi DEPARTMENT USE ONLY c� Application Accepted by ! �flate S �, -- 1t, Area Pit or Grout inspection by Date Final Inspection by_._ - Date . --,y— Additional Comments: t I 3 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 � __ _ -_ �..r-__.--_�-_�_____�� _-----,_.��__�.r......_.._•_.. AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY GATE PERMf7'NO. INFO CASH . EH 1 3-24iREV,iin5 , /!i �y5. (VO. -+! l) �I {'� EH 13.26 �J" 1' I� f 1!