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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 P 0 BOX 2009, STOCKTON, CA 95201 .PRMII: 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 and Regulations of San Joaquin County Public Health Services. ,�^��'/�; Job Address / - ) City Yr I� Yofk Lot Size/Acreage n Owner's Name r`4 KCk eM Ma—e-1 Adclress-1�� cP T_(_ _ Phone Contfactor I K Address • 0* L 0 1 VQ �)d 11— License Nq[_� Phone TYPE OF WELL/PUMP: N W WELL WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION ` SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK E[�� SEWER LINES DISPOSAL FLD._ _ PROP. LINE t?27� r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPSf__SL70 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIRNS — r Ll Industrial Open Bottom ❑ Manteca Dia. of Well Excavationr Dia. of Well Casing O?omestic/Private ❑ Gravel Pack L7 Tracy Type of Casing e fr Specifications Public C1 Or the( 171 Delta Depth of Grout Seal Type o Grpu_�ilt.�e° , f 1 i I Irrigation �.Approx. Depth l I Eastern Surface Sedl Installed by V a t' -, fZ, I i nT Repair Work Done L3 Type of Pump S L2 H.P. 3 _ State Work Done _ Well Destruction O Well Diameter Sealing Material & Depth Depth Filler Material & Depth q `; TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION f I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of sail to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity__ No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of tines Total length/size ~'7 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 ) Depth Sire Number SUMPS Ll Distance to nearest: Well Foundation Property Line �f 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: "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 applicantAust call for all required inspections. Complete drawing on reverse side. Sign X Title: S ( JLe°S- Date: ._'7,be_,ArJ OR DEPARTMENT USE ONLY Application Accepted by z Date Z Area Pit or Grout Inspection by 7 Data J Final Inspection by Date i Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services ` 1601 B. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201FEE f INFO MOUNT DUE MOUNT REMITTED CASH RECEIVED 9Y DATE P MI7'NO. C� + EH 13-21(REV, /n5i �� &5,�Q /'') r EH 51-26 �l r