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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 O BOX 2009, STOCKTON, CA 95201. PERMIT EXPIRES 1 YEAR FROM 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 aad Regulations of San Joaquin County Public Health Services. .] I j � () 1 � * Jab Address t" � 0 V1 C_ � city v� Lot Site/Acreage.,_. Owner's Name -i�}'�^'L�GS t-0 Address 1 �4 �/"t O+'1 G�� Phone 3 f 0 Contractor^� '�—P—_ __ ___Address License No. Phone TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT 0 DESTRUCTION Cl Out of Service Well 0 PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER EI Monitoring Well L7 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 V C71 Industrial O Open Bottom [D Manteca Dia. of Well Excavation Dia. of Well Casing 11 Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications I'I Public CI Other n Delta Depth of Grout Seal Type of Grout (�`y I I Irrigation —Approx. Depth I l Eastern Surface Seal Installed by �` t Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction O Well Diameter Sealing Material & Depth Depth Filler Material & Depth O TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I " DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence +! Commercial_ Other Number of living units: ___L Number of bedrooms _ Character of soil to a depth of 3 feet: S'Q!r'Y1 is , L a "^'� Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartmenis m PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE I?"-`No. & Length of lines } 37-6 :SIR De- Tptal length/size jr FILTER�BED f jstance to nearest: Well Q� '� F undation � Property Line �- i SEEPAGE PITS I I 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 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: "1 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 mfit call for all required inspections. Complete drawing on reverse side. Signed X Title: (I 14 /P n _ Date: fl F1 DEPAR ENT E ONLY Application Accepted by Date rea Pit or Grout Inspection by Date Final Inspection b Dated 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT H0. . EH 13-24 IREV.i i H 51 EH i4-2e