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APPLICATION FOR PERM I T SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES , ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOR 2009, STOCKTON, CA 95201 , PERMIT EXPIRES 1 YEAR FR9M-.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 Servic s. J f /�} /�� Job Address — L 3 4 t[/V W "Jey /�f� City 401 Lot Size/Acreages/ Owner's Name / (f �� Address Phone Contractor �f?y Address �t ® f/Q_ License No. Phone TYPE OF WELL/PUMP: NEW WELLX, WELL REPLACEMENT ❑ DESTRUCTION Out of Service well ❑ PUMP INSTALLATI SYSTEM REPAIR ❑ OTHER ❑ Monitoring well C7 ' 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 SPECIFICATIO.US t n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excava n Dia. of Well Casing #"Domestic/Private Gravel Pack ❑ Tracy Type of Casing Specifications - I'i Public [1 Other F1 Delta Depth of Grout Seal T pe of Grout.-y-Aar*_ I i Irri{fation 3420L-.Approx. Depth I I Eastern Surface Seal installed by Repair Work Done 0 Type of Pump H.P. States Work Done We11 Destruction ❑ Wel! Diameter Sealing Material & Depth e� Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it 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 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size 4 FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1 SEEPAGE PITS 11 Depth Size _ Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work wila done in accordance with San Joaquin county ordinances, state laws, an rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that 'n the performance of the work for which this permit is issued, I shall no 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 i-nAhe performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Califor a." The applicant call foral! r fired inspections. Complete drawing on reverse side. Signed Title: Date: /Q ,Z' � ' FOR DEPARTMENT USE ONLY q Application Accepted by Dateres © � - 1 _ 4� VW JP,_ ?pG Pit or Grout Inspection by +-t-�A_- ate �O-7�-�( 2 Fina! Inspection by%-' O-� # 9 Date' -13 Additional Comments: t I Applicant - Return all C s to:-)San Joaquin County Public Health a P$«'x Services, ,Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 ox 2009, Stockton, CAH FEE AMOUNT DUE AMOUNT REMITTED CK H ECEIVED 8Yp TE P RMI a EH 13-24{REV.1/m sl EH:4-2s !Z^ Y t®�