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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 /vo P 0 BOX 2009, STOCKTON, CA 95201 PBMIT EXPIRES 1 YEAR FR m ATE ED .n (Complete in Triplicate) Asst I 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 end Regulations of San Joaquin County 7Public Health Services. r`colc b Address �iK -r Qn��t City Lot' Size/Acreage ner's Name iI �7 �^L Address �/�� Phone —�� r ntractor Address License No, Phone PE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAI ----'0 TH EFt C1 Monitoring Well C3 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINEDISPOSAL FLD. PROP. LINE FOUNDATION A LTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL OBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bot 11 Manteca Dia. of Well Excavation Dia. of Well Casing F- Domestic/Private ❑ G Pack L1 Tracy Type of Casing Specifications I'1 Public Other n Delta Depth of Grout Seal Type of Grout I I Irrigati .._.,. Approx. Depth l I Eastern Surface Seal Installed by Repair W,;-&-n, C3 Type of Pump H.P. State Work Dona _ Sealing Material 6 Depth Wall Destruction ❑ Well Diameter n6 � Depth Filler Material b Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTIO 1 fNo septic system permitted if public sewer is available within 200 leet.j 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 `, J PKG. TREATMENT PLT, ❑ Method of Disposal Distance to nearest: Well Foundation Property Line Z LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED 177 Distance to nearest: Well Foundation Property Line I SEEPAGE PITS 11 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 wilt 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 appMC ust call for all required inspections. Complete drawing on reverse side. Signed Title: �� '� _,..-. Date- !70 R f ARTMENT USE ONLY Application Accepted by c"ar Dale S r Area Pit or Grout Inspection by Date Final Inspection by J� �7—� Date Additional Comments: 0 r>�V 1,Q LLc -errs Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services �� 1601 E. Hazelton Ave., P 0 x 2009. Stockton, CA 95201 FEE INFO AMOUNT DUE MOUNT REMITTED C H JV I RECEIVED BY DATE PERMIT NO. i XR-N. + EH 13-24{REV.t i k 51 �� EH 74-2e