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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ;y ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 E P 0 BOR 2009, STOCKTON, CA 95201 ' t JURMIT 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'vith San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San 4 Joaquin County Public Health Services. 'i Job Addressli7 City 5 f 6GkaEI Lot Size/Acreage i Owner's Name 0a(r}14 S rv. ,P rr--/Z-Addresss SCn�f c� Phone- Address vW License No. s- Phone - -TYPE-OF WELL/,PUMP: - - r NEW WELL-•❑- - -WELL REPLACEMENT ❑ -DESTRUCTION ❑ Out-of Service Well. ❑.. r 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 PRO13LEM AREA CONSTRUCTION SPECIFICATIONS t n Industrial ❑ Open Bottom i ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i -E.I Domestic/-Private ----0--Gravel Pack ❑ Trac Type of Casing Y Yp - 9Specifications � �tl'1 Public Cl Oihery n Delta Depth of Grout Seal Type of Grout i 3 W'1 i Irri ation A e f 0- .�.. pprox`:,,Depth I I Eastern Surface Seal Installed by. xRepair Work Done U .Type of Pump H.P. f State Work Done l Well Destruction '' 0 Well Diameters Sealing Material & Depth Depth Filler Material & Depth 'TYPE OF SEPTIC WORK: NEW INSTALLATION EPAIR/ADDITION ( I DESTRUCTION I I INo septic system permitted it public sewer is.- available within 200 feet.) r Installation will serve: Residence4,'Commarcial Other 1f► t Number of living units: Number ofabedrooms r { A ` Character of soil to a depth of 3 feet: Water table depth / s :SEPTIC TANK- fid'-Type/Mfg � G ie, Capacity No. Compartments PKG.-TREATMENT PLT. ❑ t' Method of Disposal r "� � Distance t nearest: Well Foundation Property Line i LEACHING LINE �No. & Length of lines —_(� —' �� Total length/size NO E FILTER BED 1-1 Distance to"nearest: Well � -Foundation 415 i Property Line SEEPAGE Depth Size fr Number .. r SUMPS ( I Distance to'nearest: Well Foundation^.� _ Property Line Pi TS DISPOSAL PONDS p r t. 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, ands .. rules and regulations of the San Joaquin County t i Home owner or,licensed agent's signature the followin ' 9 0 g: "i certify that in the performance of the work fol•which this permit is issued, I shall not'; i employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signatures 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 req fired insPections. Complete drawing on reverse side. Signed XTitle: —i� eAr/ „_.. Date: c "f1 rte ORPART E T.USE ONLY j Application Accepted by Date i r Grout Inspection by Date ��.� 6 Final Inspection by Date Additional Comments.- Applicant omments:Applicant .;Return all copies to: . San Joaquin County Public Health ! Services, Environmental Health Permit/Servicea i ''. ., l: 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201FEE . INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 6Y DATE PERMI7'NO. i EH 13-24"fREV,I H!5)