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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL ,HEALTH DIVISION 1.601 E. HAZFLTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISUED (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. JF.S;11 J/� a Job Address J d tl J �Q� 7 Cit of Size/Acreage Owner's Name �rtfD ?e ie,, /iel�vw. Address P� 8� _��_f , `-� 00 Phe Contractor Address P O -9 QX 1 Q Z7 Licens~NoJ1�13 73 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Q DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR W--' OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS NTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS WIFInclustrial ❑ Open Bottom C3Manteca Dia. of Well Excavation Dia. of Well-Casing 411 !WrDomestic/Private ❑ Gravel Pack Ll Tracy Type of Casing Specifications N, I'1 Public I-1 Other 171Delta Depth of Grout Seal Type of Grout O I I Irrigation Approx. Depth It Eastern Su ace Sedi Installed by Repair Work Done Ir/Type of Pump —594 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 I I (No septic system permitted if public sewer is available within 200 feet.i Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: X Water table depth SEPTIC TANK ❑ Type/Mfg Capacity-- No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal I Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size t FILTER BED Cl Distance to nearest: ell Foundation Property Line- SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance ton rest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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, 1 shall not employ any perso . such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the f owing: certify that in the performance f the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws o California.' The appli nI st r all r it s ns omple a 6f side'. Signed Title: Dais: 42 +/ 172-- FOR DEPARTMENT USE ONLY Application Accepted by Date D — +�Area d 2 { L Pit or Grout Inspection by Date Final Inspection by Date� � Additional Comments: • Applicant — Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 9. Hazelton Ave., P Ojk2x 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE A UNT R MITTED CAS if RECEIVED BY ATE PERMIT NO. EM 13.241REV. /A5) O^ � EH 41.2a ^ L 70