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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT RES 1 YEAR FRQM 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 1862 and the Rules and Regulations of San Joaquin County Public Health Services. ,.� (� lk —� . / Job Address -� M„ o 11 �Q'� _ �V .City JZ I +' O VI Lot Size/Acreage 440 � ++�� ^ Owner's Name �-r $I VO b )'CrAddress 4��_„J_ 1"! n i 1r -Phone Contractor Address X7 7 a. 14 s^R License fVo. U Phone 11 2 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 0 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 C-1 Industrial 0 Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing C-1 Domestic/Private 0 Gravel Pack D Tracy Type of Casing Specifications I'1 Public Cl Other F-I Delta Depth of Grout Seal Type of Grout I i Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by bp Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material 6 Depth Depth Filler Material S Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I DESTRUCTION I I (No septic system permitted if ptiblic sewer is available within 200 feet.1 installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms t Character of soil to a depth of 3 feet: 7 'D L-.-a A-*—) . Water table depth r S SEPTIC TANK WeATwelmlo �' G O to C -e Capacity M 06 4 160Qo. Compartments Z PKG. TREATMENT PLT, ❑ 1Z Method of Disposyl Distance to nearest: Well�Foundation ' Property Line 1 0 0 lf` wQ-�'Go1L c9 u f oL -+of l v v� *4 I'L Oo 1%,c1. r 40 LEACHING LINE 0 No. & Length of fines Total length/size 0-6 • FILTER BED n Distance to nearest: Well Foundation Property Line Gam+ tt1.v V P 0 le— SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant m t c II far a required in ctions. Complete drawing on reverse side. Signed Title: Date: r/ FOR DEPARTMENT USE ONLY rp Application Accepted by Date as Area 1 (, Pit or Grout Inspection by Date Final Inspection by Data a Additional Comments: Applicant - Return alll copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 13-24 IREV.i i n ar EH 14-26 1 !� -