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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 DATE ISSUED (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 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. I Jab Address ZG773rTc / 2� 40- City /+dOdSize/Acreage [� Owner's Name �� LU IJ Address 5'4_44e PhoneC1 i Contractor " "04C Address V, GtJ' 6C 1_5 = License NomPhone/L TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSt REPAIR 7Ei OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f� Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing 'Domestic/Private ❑ Grave! Pack ❑ Tracy Type of Casing Specifications I'1 Public Ia Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done X Type of Pump !F46, H,P. � ,____-1 -- State Work Done /�✓f Well Destruction ❑ Well Diameter Sealing Material & Depth , `•1 e�6yL, 9 Depth Filler Material & Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I k REPAIR/ADDITION I I DESTRUCTION 1 i (No septic system permitted if public sewer is `available within 200 feet.) Installation will serve:. Residence_ Commercial____ Other Number of living units: Number of bedrooms - x Character of soil to a depth of 3 feel: Water table depth 4 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKC. TREATMENT PLT. Cl - -- _ .. _., w ;. Method of Disposal I Distance to nearest: Well Foundation'"— Property Line LEACHING LINE D No. & Length of lines r = Total length/size FILTER BED ..- ❑ Distance to nearest: Well* ` Foundation Property Line SEEPAGE PITS ( I Depth Sue a _ Number SUMPS El Distance to nearest: ° Well 'J :Foundation'� Property Line DISPOSAL PONDS ❑ 1 r . 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 applica call for all required inspections. Complete drawing on ver side. SignedX Title: pate: R DEPARTMENT USE ONLY Application Accepted by C� „9�L s�, , ,._(.'.,�n,� Date -a� Area C-�y Pit or Grout Inspection by Date Final Inspection by.. Date „ ,.._, 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 FEEp INFOAMOUNTD�`tJE AMOUNT REMITTED CASH RECEIVED BY DAVE PERMIT NO. + EM 13-24IREV.$/A 5) EH 14.20 111 a p