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r APPLICATION FOR PERMIT �f SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ' ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 ,PRYIT EXPIRES I YEAR FROM DATE ISSUED (Complete In Triplicate) Application is hereby made`to Sam 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 Sler/vices. sr�� y1 Job Addres _�__ 7Yl�t.tE�7- -__ City Lot Size/Acreage I n � FfR F'` 1 f" ��. i��!t3 c��9 Phone Q -a a 4 7 - Owner's Name �r�� ° I—, ' �� Address Conlraclor a� 1 t ff,rn I Address-pQll�f�,(1)DN License NoOC r 3�K3 Ph,, TYPE OF WELL/PUMP: NEW WELLA WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well ❑ E J PUMP iNSTALLLA710N SYSTEM REPAIR C7 `OTHER._❑ Monityorr. ...ing Well 0 DISTANCE TO NEAREST: SEPTIC TANK' �L,Q� SEWER LINES DISPOSAL FLD. PROP, LINE L[2_ . . 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPSf.'�_O INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS { ❑ industrial f'01, bpen Bottom,- ❑ Manteca Dia. of Well Excavation Dia. of Well Casing >(—Domestic/Private "O Gravel Pack jam} L7 Tiacy Typs of Casing ° Y P'&I Specifications 1 I'] Pilbllc I Other�l t n Delta Depth of Grout Sea! r r` Type f Grout. �� esa�w 'N ! I Irrigation 03&Apprax. D.eppth ' I I Eastern / urface Seal Install4d_by r h Repair Work Done CJ Type of Pump ` H.P. �� State W Done ` Well Destruction 0 Well Diameter Sealing Material S Depth f Depth"`�" ' _F.iller�l+idterial &Depth ' TYPE,OF SEPTIC WORK: NEW INSTALLATION I I REPAIR`/,ADDITION 1 I DESTRUCTION l 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ — Commercial_ Other ` Nuvnber of living units: Number of bedrooms Character of soil to a depth of 3 feet: r ! `,- 3 P ' ` Water table depth SEPTIC TANK p Typa/Mig Capacc by No. Compartments PKG.(TREATMENT PLT. 0 Method of Disposal �> Distance to nearest: Well Foundation �Property,Line r. LEACHING LINE CINo. f4 Length of lines Total length/size 4i y FILTER BED 0 Distance to nearest: Well Foundation Property Line -- — -- f ' J SEEPAGE PITS I I Depth Sire Number ' " SUMPS LI Distance to,nearest: Well Foundation L` .Property Liner t 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 els i 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." �"I}�� I The applicant must call for all required inspections. Complete drawing on reverse side. 1 Signed k92 Title: 1 Date: I _ FOR DEPARTMENT USE ONLY C Application Accepted by Ar"I Date a,- �' At 2- Pit or ro Inspection by / ate Final Inspection b Date`7 =.�� Additional Comments: t1f Applicant - Return all copies to:�.Ban Joaquin County Public Health t Services, Environmental Health Permit/Services �yd� 1601 E. Hazelton Ave:, P 0 Box 2009, Stockton, CA 95201 r (NFO FEE AMOUNT DUE AMOUNT REMITTED C J RECEIVED BY DATE,r PERMIT'NO. tiw qt i S7. EH 13-24(AEV,i/n EH 757ALe- `�C)14-20