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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 O BOX 2009, STOCETON, CA 95201 1j; PEWT EXPIRES 1 YEAR FROM DAIR ISSUED RE (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 glade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. j,, f P Job Address `-� City "'"��, Lot Size/Acreage ` 0 Owner's Name L�e rC II r�l Address Phone 1, �J Q� �t 1l 3 E Contractor VP 5 Address vat 7 License No. r Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEM NT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I f-1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C i Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type'of Casing Specifications c. I'I Public la.Other n Delta Depth of Grow Seal` Type of Grout C) I I Irr 9ation {_'.Approx. Depth l l Eastern Surface Seal Installed b " Y Repair Work Done 0 T pe. "Bump H.P. State Work Done— Well Destruction ❑ Well Diameter_ Sealing Material A.Depth ' "Depth Filler Material E Depth n, TYPEIOF SEPTIC WORK: NEW INSTALLATION I ]-,"REPAIR/ADDITION X DESTRUCTION I I (No septic system permitted it public sewer is -" available within 200 feet.) Installation will serve: Residence_ Commercial Other Number of living units: Number of edrooms 0 Character of soil to a depth o-f 3 teat: a��e Water table depth SEPTIC TANK ❑ Type/Mfg ET 1 S [ )4 Capacity No. Compartments PKG.(TREATMENT PLT. ❑ Method of Disposal ` Distance to nearest: Well Foundation Property Line LEACHING LINE No. 8 Length of lines n� Total length/size �J FILTE BED ❑ Distance to nearest: Well rte- Foundation/-M—' 30DProperty Line . _, SEEP(AGE PITS Depth Size l 92 Number a- r SUMPS LI Distance to nearest: Well Foundation &1ZI 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 Homeowner 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." " Thea licant ust call for all inspens. Complete drawing on reverse side. Signed Title:-G�.+r4� Date: R TMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date 2 Additional Comments: Applilcant - Return all copies to: San Joaquin County Public Health ii Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P O Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH REC ED BY DATE PERMIT NO. EH 13.24 1REV. 2Z-� & 9/-/Of y'`.EH 14.28 / !�.