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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 1662 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address �/`7* 61-, �; // vtl City �'Z44�!4' Lot Size/Acreage Owner's Name VlN -4J'�-�K A 1-_-__ _- Address "r� Phone ^^ 1 Contractor /rte r J' Address O l3� License NJ?-?3 Fr Phoneme y�y7 f TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION 5K Out of Service Well ❑ PUMP INSTALLATION J5;C SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Weil Casing Domestic/Privateravel Pack C] Tracy Type of Casing Specifications Il Public Cl Other n Delta Depth of Grout Seal y7 Type of Grout__ Com± t IQ! I I Irrigation Z�,14 ..Approx. Depth I I Eastern Surface Seal Installed C 75-k „ Repair Work Done L] Type of Pump __S'01__ H.P. _U State Work Done e J (�'J Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIRIADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.1 Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soil,to a depth of 3 feet: Water table depth POP SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PET. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 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 subcontracting 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 must call for all required inspections. Complete drawing on reverse side. 1 Signed X Title: L. Date: 7 OR TM ENT USE ONLY � 1 Application Accepted`by Date Area Pit ortGrlut nepection by Dyate j Final Inspection by' n^ Date Additional Comments: Applicant - Return all copies to: San Joaquin County Pu lFO alth Services, Environmentalth Permit/Services 1601 E. Hazelton Ave., ox 2009, Stockton, CA 95201 V,� CK JFO EE AMOUNTDtl£ AMOUNT REMITTED CSH RRECEIVED BY DATE PERMIT'NOtE �� EH 1, Gil— lc>�9g