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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. RAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES-1 YEAR FROM DATE 15SUED (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. r Job Address City 1 S'col'd 0 Lot Size/Acreage . Owner's Name Address " �� _ Phone Contractor J A: of 4�74It,*r -_Address ! © JUDY �� License No ?6ayzl Phone ^� TYPE OF WELL/PUMPS I NEW WELL ❑ -WELL REPLACEMENT 4 -- w DESTRUCTION-i—Out ofService We-l1 ,❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well [3 DISTANCE'TO'NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP:,LINE 6 FOUNDATION AGRICULTURE WELL OTHER WELL-,i.- - -p9S/SW MPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIONS SPECIFICATIONS �r D Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing 1 Domestic/Private, ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 11 Public [I Other fl belta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work aone- -0 - Tlpe of Pump H,P. State Work Done Depth & De t M Sealing Material p Wel! Destruction 0Well Diameter Sea � Cl1 Depth Filler Material"W'Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITtON Pr DESTRUCTION ! I INo septic system permitted if public sewer is _ available within 200 feet.) Installation will serve: Residence= Commercial_ Other Number of living units: Number of bedro ms_. 11�= _ Character of"soi{to a depth of 3 feet: ' a d / Water table depth SEPTIC TANK: ❑ Type/Mfg _ a Capacity -i No. Compartments PKG. TREATMENT PLT. ❑ Method pf Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0--`No. & Length of lines It— length/size ` FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size�;� _ Number C' SUMPS W Distance to nearest: iWell I D32 _ Foundation Property Line ld� -- Q 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 w 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 applicant must call for all re fired inspections. Complete drawing on reverse side: Signed X 9 41 4 Title: 40ea t Date. JX) Fd F - DEPARTMENT USE ONLY Application Accepted by Date O Area Pit or Grout Inspection by Date Final Inspection Oy Date 7 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. + EH 13-21(REV.t/N51 [ O— EH 14.26 1 V