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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 BOR 2009, STOCKTON, CA 95201 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 coatpliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. /3 q Job Address � /City LotSi_z�e/Acreage d> r7 axA_i Owner's Nam , ^ Address ` 7 , /L G7. Phone 33`t — 2 Q(p rp Contract r2 Address fJ, License No ? a 7 z Phone 36 IS-3/0S TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ 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 n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing f:] Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I"I Public Cl Other n Delta Depth of Grout Seal _ Type of Grout I I Irrigation w Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump. H.P. State Work Done Well Destruction - ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I 1 DESTRUCTION I I INo septic system permitted if public sewer is UJ available within 200 feet.) _ Installation will serve: Residence Commercial_ Other Number of living units: / Number of belboms �c— Character of soil to a depth of 3 feet: Water table depth J SEPTIC TANK. Type/Mfg r Capacity 4d No. Compartments PKG. TREATMENT PLT. ❑ e f Method of Dit�osal Distance to nearest: Well S4 foundation �� Property Line_,�_ t � / LEACHING LINE - No. & Length of lines — Total length/size X FILTER BED ❑ Distance to nearest: Well Foundation _Lt'J.f .Property Line SEEPAGE PITS ,`KI: Depth Size Number i SUMPS LI Distance to nearest: Well 106 `Foundation ' Property Line DISPOSAL PONDS _ - Cl r 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 oCthe 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 t call for equ'ed inspections. Complete drawing on reverse si Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted b�^ Date J " / �(� Area 1 it r Grout Inapaction by Date final Inspection by Dat 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 fEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH . EM 13-241AEV- /85l `� EH 74•Ze /