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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 0 BOR 2009, STOCKTON, CA 95201 PRIMIT EXPIREg 1 YEAR FROM DAIE 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 Publics Health Services. Job Address ^ CityAn�._A�ot Size/Acreage (�56zc_. Owner's Name r Address ._Qy v T 1�9�0C � hone, Contraclor ,4 _--_- Address License Ne �"L� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER p 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 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications f'l Public 1-1 Other 1`7 Delta Depth of Grout Seal Type of Grout r I I Irrigation —_Approx. Depth I i Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. --- State State Work Done� Q Well Destruction ❑ Well Diameter Sealing Material & Depth I Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION INo septic system permitted if public sewer is available within 100 feet.) I Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedroomm= E%A1P1REQ,,, ,,b,,_d,p,, Character of soil to a depth of 3 feet: + rym SEPTIC TANK ❑ Type/Mfgc' R U'�lo. Compartments PKG. TREATMENT PLT. ❑ a k hod of Disposal Distance to nearest: V*w4halfto;emp od or Inspogine LEACHING LINE ❑ No. & Length of lines 9 v Total length/size FILTER BED Cl Distance to nearest: Well Foundation_ ._...._Property Line SEEPAGE PITS I I Depth Size Number I SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 1 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: "! 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 California." I The applicant t call for all re ins tions. Complete drawing on reverse side. p Signed Title: C(1 �'" Date: FZ DEPARTMENT USE ONLY F O� Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date 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 INFE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-NO. . EH 13-2,SREY.,/K 5l OCA ca EH 14'.261'�/t/ � h