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APPLICATION FOR PERMIT .� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 4 p 0 BO% 2009, STOCKTON, CA 95201 DFMIT EXPIR$S 1 YEAR FROM DATE JA1LD (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. J ,(C (� S a�( CityJd49s1 Lot Size/Acreage Job Address � Owner's Name s f)a1e Address �/�� Phone339-93 6 6 3 , �i/Lb ST' Address '`a '✓ 7 e License Na?73js Phone Conlraclor •� TYPE WELL/PUMP: NEW WELL WELL REPLACEMENT CJS DESTRUCTION ❑ Out of Service Well ❑ OF "%"'-07HER ❑ Monitoring Well C] PUMP INSTALLATION SYSTEM*aREPA]R,.0 r DISTANCE TO NEAREST:_SEPTIC,TANK/_tD ---SEWER-LINES- DISPOSAL FLD.1_'57-'>_-,PROP. LINE �• FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENOEI] USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing b Cl Industrials ❑ Open Bottom ❑ Manteca Dia. of Well Excavation T s of Casing Specifications domestic/Private Gravel Pack L7 Tracy VP 0 Type of Grout { F1 Public j 1-1 Other {I Delta Depth of Groutal �_ Approx. Depth 3Dh I I Eastern.T Surface Seal Installed by �- I I Irrigation �� ; Repair Work'Done [7 Type of Pump — H•P. State Work Done Well Destruction- ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet,l Installation will serve: Residence— Commercial ;Other Number'of living units: Number of bedrooms Character of soil to a depth of 3 feet: l Water table depth 1 SEPTIC TANK , ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ tI Method of Disposal Distance to nearest: Well Foundation Property Line t f - , LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well 4 Foundation Property line SEEPAGE PITS 11 Depth Size Number SUMPS 0 Distance to nearest: well Foundation 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 G r r Home owner or licensed agent's signature certifies the following: "1 certify that in the performance.of.the work for which this permit 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 canifies 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 f r all r wired inspections. Complete drawing on reverse side. l — Title: ' •ate i Date: l0_ZS—gam ` Signed )(� - JOER DEPARTMENT.USE ONLY Application Accepted by Date '" V Area Pit �rout pection by ate Final Inspection by t ` Date + Additional Comments: N Applicant - Return all copies to: San Joaquin County blic Health Services, environmental health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201CK a �+J FEE AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT 1J0, INFO k ^ R 90 acal 4 EH 1324iAEV.r�Xsf �� l�q �v �`p r It EH 542E ;