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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC REALTH- SERVICNS ENVIRONMENTAL.. HEALTH DIVISION ,- 1601 .].60]. E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009; STOCKTON, CA 95201 k � PERMIT 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 1$62 and the Rules and Regulations of San Joaquin County Public Health Services, [p} t Job Address / e 1 POA) City/ &/ Lot Site/Acreage_' ��t t AGc-�7J-� k ,T6/✓l 14L�D GARk Address t Owner's Name _ G J0 Phone /1Yt f r� - . _ d� --Phhone.. Contrattor Address' f�6� License No:�T TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ,❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ —� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLU. PROP. LINE t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11 Industrial 11 Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing l N Domestic/Private Cl Gravel Pack L7 Tracy Type of Casing Specifications CI Public i-1 Other ❑ Delta Depth of Grout Seal Type of Grout �^0 I I Irrigation ,"��., s ` Alpprox. Depth I ) Eastern Surface Seal Installed by L' Repair Work Done 0 Type of Pump H.P. S14:to Work Done > ` Depth & De i t M Sealing Material p ' Well Destruction ❑ ' Well Diameter Sea "— i ? Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW,-INSTALLATION I I REPAIR/ADDITION• DESTRUCTION-1 i fNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: y Residence_L Commercial_ Other z r. ;r, Number of living units'_4_L'" Number of bedrooms Character of soil to a depth of;3 feet: _ rAinJ�./ Lha Water table depth SEPTIC TANK. `❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.;CI I Method of Disposal Distance to nearest: Well Foundation 'Property Line - LEACHING LINE '� No. & Length of lines =/_420 o,7 fx : "Total.fength/size �T FILTER BED `.,w D Distance to nearest: Well LW 0` Foundations � Property Line i SEEPAGE PIT S'I' '' 11 Dbpth Size Y Numbers I SUMPS ` y ' 3 ' Ll Distance to nearest: Well Foundation Property Line f DISPOSAL PONDS _0-'_0 > I hereby ceniN-thaf I-haYe`preparad 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 S Home owner of-licensed-agent's-signature'certifies the following: "I-certify that in the'pertwmance`of the work.for which this permit is issued, I shall not employ any person in such manner as to beer ne',stib;J�Iict to workman's c6rhpensation laws of California," Contractor's hiring or sub-contracting signature certifies the fotlowing: "!ce'itify that in the pertormance''of the work fOf,rihich this permit is issued;I shalt employ persons subject to workman's compensa tion laws of California." I The applicant.must call for.al equir d inspections. Complete.;drawing on reverse side. w... r Signed X Title: e I Date: FO P ONLY Application Accepted by 9— Pit Pit or Grout Inspection by Date Ficial lnspdction by Dat�"� Additional Comments: Applicant -Return all copies to: San Joaquin County Public Health r' Services, Environmental Health Permit/Services l 11/ S 1.601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 INFO EEE AMOUNT DUE AMOUNT REMITTED CK f CASH RECEIVED BY DATE PERMIT NO. ;{ s 77 . EN 13.241REV.;1 51 5H 14-2e