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i` APPLICATION FOR PERMIT I€ SAN JOAQUIN COUNTY`PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION. 1601 E. HAZELTON AVE. , PHONE (209)468-3420 STOCKTON - CA 95201 P O BOX 2009,`- M P7�RlITT EXPIRES 1 YTsAR FROM DATE § ED (Complete in Triplicate) li 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 1862 and the Rules and Regulations of Ban Joaquin County Public Health Services. Job Address Y City 4 Lot Size/Acreage t0 r Owner's Name Address Phone ni ddress gee Ro gi License No. ��_LPhone Contractor Qr �Q TYPE OF WELL/PUMP. �� ._ NEW WELL WELL REPLACEMENT C� DESTRUCTION Cl Out of Service Well ❑" r Monitoring Well' PUMP INSTALLATION Ck SYSTEM REPAIR El OTHER ❑ ❑ a 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 SA, {] Industrial ❑ Open Bottom El-Tracy Dia. of Well Excavation Dia. of Well Casing �LDomestic/Private (,Gravel Pack ❑ Tracy -- µ - -Type of Casing t - Specifications I'I Public f:1 Other 1-1 Delta _ Depth of;Grout Sea* �Z Q 1 y��7-- �Type of Grout f I I IrrigationTypo Approx.... DepthT _ I 1 Eastern Surface Seal installed by . �,I ,.r � -3 . � State Worke Dana, Repair Work Done : 0 of Pump �' H•P- Well Destruction ❑ Well Diameter Sealing Material ii Depth ' Depth "Filler-Mate-rial 6 Depth"_..f. . TYPE OF SEPTIC WORK: NEW INSTALLATION 1"1 REPAIR/ADDITION i I :DESTRUCTION I I" INo septic"system-permitted if public sewer is ii t available within 200 feet.) Installation will serve: Residence Commercial Other " ' Number of living units: Number of bedrooms Character of soil to a depthof 3 feet: Water table depth SEPTIC TANK. ❑ `"Type/Mfg Capacity'" Y " No. Compartment's PKG. TREATMENT PLT. ❑ Method of Disposal (Distance to nearest: Well Foundation Property Line .u. LEACHING LINE D "No. & Length of lines k".Total lengthl/size FILTER BED U ',Distance to nearest: Well Foundation ''Property Line m SEEPAGE PITS 1 l I &pth Size Number.'" SUMPS i LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS( D y� I hereby certify that I have prepared this application and that the work will be done in accordarice with.San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County- '.', , t°" t ' Home owner or licensed ag_ent's signature certifies the followind: "I certify that in the performance of the work for which this permit is issued, t shall not f employ any person in such ri5annrst as to become-subject to workmanLs compensation laws of California;",Contractor's hiring or sub-contracting signature k certifies the following: "I certify that in the performance,of the work for which fNis'permit•is-issued,4shall.employ persons subject to workman's compensa- tion laws of California." The applicancal or all r7 " inc' Complete dra 'ng on reverse side. �' Il . Signed Title: tr D ate:" i E FO DEPARTMENT USE ONLY I Application Accepted by Pit o(grouInspection Date Fin Inspe tion b ` Dated -� t r Additional Comments: 'L Applicant - Return all copies to: San Joaquin County Public Hea Services, Environmental Heal Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH �ry0 9 U. EMA i1-- t1 . EM 20 IItEV.r)H 5) ',]'b �3 T7 t N 28 " t �� - 0, -:_..