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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I� . ENVIRONMENTAL HEALTH DIVISION �l 1601 E. HAZELTON AVE. , PHONE (209)468-3420�I P 0 BOX 2009, STOCKTON, CA 95201 pgalT I! EXP RES 1 YEAR FR M DATE ED �I (Complete ii Triplicate) Application is hereby made.to San Joaquin County for a permit to construct and/or install the work herein described. This t application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address ')[J! City Slk _ Loi: Size/Acreage I l {�, �b L�t� v f p fl1thP I� Address, j�5 A • W `�Dn wCl�/ Phone�'/ JT 0Ir J� Owner's Name /�_J t W� - QWfr' " 4 Gantratlar r,n Address t 'a scense_No !S�b _Phone - .-r . _ . Out of Service well ❑ TYPE OF WELL/PUMP: �� r NEW WELL Cl WELL REPLACEMENT F)PUMP INSTALLATION CJ SYSTEM REPAIR ❑ OTHER Monitoring Well L3 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial C1 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wait Casing ❑ Domestic/Private ❑ ',Gavel Pack ❑ Tracy Type of Casing Specifications — FI Public M Other ❑ Delta Depth of Grout Seal Type of Grout I I irrigation J-,Approx. Depth I-I,-Eastern,!---Surface'Seai installed by # Repair Work Done 0 Type of Pump H.P. State Work Done I Well Destruction ❑ Welt Diameter ! Sealing Material & Depth 0 Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION ( 1 REPAIRIADDITION I I DESTRUCTION XINo septic system permitted if public sewer is available within 200 feet.) ' h e installation will serve: Residence •Commercial Other Number of living units: Number of bedrooms rr� water table depth Character of soil•to's depth of 3 feet: SEPTIC TANK ❑ ilType/Mfg s Capacity r No. Compartments PKG. TREATMENT PLT. ❑ �I I Method of Disposal I!I Distance to nearest: Well Foundation Property Line i r LEACHING LINE ❑ ' No. & Length of lines � Total length/size FILTER BED ❑ I Distance to nearest: Well Foundation a Property,Line SEEPAGE PITS Ii .I Depth s Size Number SUMPS Ll ! stance to nearest: Well DiFoundation Property Line DISPOSAL PONDS C3 .II. 1 - ared this application and that the work will be done in accordance with San`Joaquin county ordinances, state laws, and I hereby certify that I have prep rules and regulations of the San Joaquin County Home owner or licensed agent's signature cartifies 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." .11 I i' The applic mus call for all require i pections. C mplete drawing on reverse side. e -///411 Signed X ' Title: Date: II '�r €,Nt ,.6 FOR DEPARTMENT USE ONLY a Application Acceptedby _ Date ( I Area Pit or Grout Inspection by Ip - --Date Final-Inapsttion-bye vtn - -� 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 FfEAMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT N0. INtF/O� L CASH {� Q .+7f . EH 13-14IREV,r/nsl J '4 ,00 i—I l�J�/�• `�- t l q� � ` EH 14.20 1