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� t APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC II`EALTH SERVICES ENVIRONMENTAL HEALTO- DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 t ,gERMIT EXPIRES 1 YEAR=FROM DATE ISSUED (Complete in Triplicate) Application is hereby made.to S(,Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliancel with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. I City Lot Size/Acreage Job Address it 0 Owner's Name Aio�� AddressPhone t rf Contraclor f Address �� License No. Phone TYPE OF WELL/PUMP: V NEW-WELL'.❑ '' WELL-REPLACEMENT ❑ DESTRUCTION p Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM! REPAIR ❑ OTHER ❑ Monitoring Well L3 k DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. ti PROP. LINE FOUNDATION AGRICULTURE WELL j OTHER WELL• s PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA ' CONSTRUCTION SPECIFICATIONS' Ll Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation! "! Dia. of Well Casing C1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of CasingSpecifications I ' t 11 Public to Other n Delta Depth of Grout Seal Type of Grout j i i Irrigation Approx, Depth I I Eastern Surface Seat Installed by ` Repair Work Done U Type of Pump H.P. State Work Done T Sealing Material & Depth t Well Destruction ❑ Well Diameter _ Q Depth ' ll.r^` €;.: >".� Filler Material & Depth i TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 I s DESTRUCTION (No septic system permitted if public sewer is d \ ,} available within 200 feet.) Installation will serve: Residence! CommerciaLk�_-Other t ,: Number of living units: Nun&r 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 FILTER SED 0 Distance Co nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth G1 Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ A 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;his permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." ` The applint ust cal r I-r 2 d�inspe tions.-Complete drawing on,reverse side. Signal tl7 j-f --"-Title: -_J4yr��.n .� �ry .,. - €5_ pate: ` (� FOR DEPARTMENT USE ONLY V 1�X1VlJ Area � /q Application Accepted,by Date Pit or Grout Inspection b # Date Final Inspection by �.�_ Date b (Zho Additional Comments: DJ4 f s r� o� alP " �P4'Ir�y a t Applicant - Return all copies to: San Joaquin County Public.9ealth I #`� Services, Environmental Health Permit/Services k f 1601 E. Hazelton Ave.. P 0 Box 2009, Stockton, CA 95201 y FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED It BY DATE PERMIT'N0. INFO / /, /� J^� + EH 53-241REV.1/A5) 3,S_,6 L) 3L •oV 76,ff ,�� "G�! � 70-13s,6 EH 14.20