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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 BOX 2009, STOCKTON, CA 95201 2T"IT 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 C Ci{r t WLot Size/Acreage " �- Owner's Name s -AT ___ ____ __ Phone I Contractor Address 7 License No. Phon TYPE OF WELL/PUMP: NEW WELL ❑ Y WELL REPLA EMENT C - �t.DESTRUCTION,❑ Out of Service well ❑ 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 PROBLEM AREAS CONSTRUCTION SPECIFICATIONS r I N Industrial ❑ Open Boitom +❑-Manteca . Dia. of Well Excavation Dia. of Well Casing 1 ["I Domestic/Private ❑ Gravel Pack 0 Tracy - Type of Casing ti Specifications I'I Public i 1-7 Other n Delta Depth of Grout Seal Type of Grout I I trfi0ation —.Approx. Depth + I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth f f _Filler Material & Depth !� } TYPE OF SEPTIC WORK: NEW INSTALLATION f I -REPAI'RIADDITIO DESTRUCTION l I (No septic system permitted it public sewer is o 1 I _ available within 200 feet.) ,installation will serve: Resiid6nce Commercial_ Other RNumber of living units: . r�: :Number of Bedrooms k A _,Character of soil to a depth of 3 feet: e— Water table depth SEPTIC TANK ❑ Type/Mfg --[/Capacity ��2 No. Compartments Z PKG. TREATMENT PLT: 1J # w� `f Method of Dispos bial }stsnce'.to nearest --Well 5 Foundation, Property Line_c2C2 A. LEACHING LINE ❑ No. & Length of lines �.. Total Is 1Y FILTER BED ❑ Distance to nearest: Well�[� undatian _�Property Line / I J a k SEEPAGE PITS { I Depth _Size � Num�9r- SUMPS LI` Distance oto nearest: Well Foundation Property Line Z S22 DISPOSAL PONDS ❑ I heteby 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 t Horne 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 workmen'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 Is of a." l The applic nt must cal fa 11 re uire ctio Complete drawing an reverse side, Signed X 'tie: Z~ 1 Data: ,l FOR EfsARTMENT USE ONLY Application Accepted by ODate -a Z Area (1)10r Grout Inspectibn by e"` Final Inspection by--F _ .. ,,�•, Additional Comments: - Applicant - Return all copies to', -Sari=Joaquin County Public`Health"-- ' I Service;,-_Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stociton,—CAW 95201FEE "- 1 INFO AMOUNT DUE ,I AMOUNT REMITTED ASH RECEIVED BY DATE YERMIT'NO. . EH 13-24 IAEV.t H 5! 0•C5D t-�� (� 1 � S 3_a-��o qo _6U q ,� EH 9.4.26