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r APPLICATION FOR PERMIT i I AAN-JOAQUIN COUNTY PUBLIC HEALTH SERVICES �. _,.e ENVIRONMENTAL HEALTH DIVISION /. J 1601 E. HAZELTON AVE. , PHONE (209)468-342 r P 0 BOX 2009, STOCKTON, CA 95201 = t UNIT EXPIRES 1 YEAR FROM DATE ISSUED • I (Complete in Triplicate) Application is here t PP by made to San Joaquin County for s permit to construct and/or install thework herein described. This application is made in compliance with San Joaquin County Ordinance No. 51+9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. r 4 Job Address 1L3 '/Q City Lot Size/Acreage f Owner's Name ✓ Address`_ l(,r{ ,u h� Phone —4 Z �1 � ' Contractor. � �=�'----Address License No✓6_��Phone TYPE OF WELL/PUMP: NEW WELL �4_ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ r PUMP INSTALLATION 5? R-`` SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK- SEWER LINES- - - DISPOSAL-FLD. - - ,PROP, LINE Let! t FOUNDATION AGRICULTURE WELL 'f OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1.7 Industrial O Open Bottom ❑ Manteca Dia. of Well Excava 'on Dia. of Well Casing t/ C!t+pomesticlPrivate C Gravel Pack O Tracy Type of Casing Specifications I"I Public i El Other 171 Delta Depth of Grout Seal Z no Type of Grout I Irrigation i Approx. Dept I 1 Eastern Surface Seal Installed by r Repair Work Done Oil Type of Pump; H.P. Stats Work Dane_ Well Destruction ❑5 Well Diameter. Sealing Material & Depth IT Depth 'f Filler Material & Depth TYPE OF SEPTIC WORK: .NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I i INo septic system permitted if public sewer is t' � available within 200 feet.) G Installation will serve:' Residence- -_1'_Commercial..__.Othar___. i Number of living uniti: Number of bedrooms r " Character of soil to aldepth of,3feet:'Number -� - Water table depth I + SEPTIC TANK- ❑ T ' 1 e ` F' - ype/Mfg.• Capacity ' No. Compartments + PKC, TREATMENT PLT. ❑ � Method of Disposal _ f Distance to nearest: WeIIFoundation .. Property Line T LEACHING LINE ❑ No. & Length of lines FILTER BED Tafel length/size ❑ i Distance to nearest: Well Foundation Property Line SEEPAGE PITS '6. i I.},Depth Y 4a Size SUMPSNumber ' �U i LI . Distance to nearest: Well Foundation— Property Line DISPOSAL PONDS , ❑ F 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 Sari Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that in the performanco'of athe work for which this permit is issued, I shall not Y I 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 campensre tion laws of Califorp}np}ia."' i The applicant ni ca for all requ d inspections. Complete drawing on reverse side. -Signed ,fQh . _ .Title: Date: 7- /!'J t t FOR DEPARTMENT USE ONLY Application Accepted by Y Date ! Area 2 � -1 Pit or Grout Inspection by r W to 8 2 = Final Inspection by Date 2) �'=AZ Additional Comments: ; C I rk, r - p t o ff` ' r Applicant - Retura all copie to: 4. Joaquin County Public Health lv S ['4.9, I l Services, Environmental Health Permit/Services r 1641 E. Hazelton Ave.. P 0 Box 2009 Stockton CA + � 95201 # FEE AMOUNT DUE AMOUNT REMITTED ►I�NJFO CASH RECEIVED BY DATE PERMIT'NO. a EH1211REV.i fFt 144.2a in Ss {�rDj 1-3 ,� `J ij� I� (7 ` -A W 1 T� k