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APPLICATION FOR PERMIT fomECEIVED SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION NOV 9 im 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 ENV R QNMENTAL #HEALTH EXPIRES-1 YEAR FROM D- ED Of 49 VIC91 lI - I (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 i Job Address U ` ar'rbJ Ale-'_ --- .-- City 66:el1 Lot Size/Acreage 016 ld f4 Phone -& Owner's Namm�e e[ __ Address // '' '] Contractor �l Address / Se�Cl"i ense No. LI of Phone zck TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION , - SYSTEM REPAIR ❑ OTHER p ' Monitoring Well 11 ` DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE {. FOUNDATION -AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing VDomestic/Private .9 Gravel Pack ❑ Tracy Type of Casing Specifications �w j I'l Public [I Other n Delta Depth of Grout Seal Type of Grout t I Irrigation _Approx. Depth I I Eastern Surface Saul Installed by Repair Work Done L] Type of Pump r H.P. State Work Done Well Destruction 0 Well Diameter _ � Sealing Afaterial & Depth Depth �Zd Filler Material & Depth - TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is ----.-available-within 200 feat.l- - Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE L-) No. & Length of lines Total length/size FILTER BED 0 Distance to nearest. Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LlDistance to nearest: ._ .,Well -Foundation -• Property-Lines - ...... 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 Home owner or licensed agent's signature certifies the following: '9 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 taws of California." Contractor's hiring or subcontracting 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 C rnla." The app"c t m st call r al equired inspec. ns. Complete drawing o ver/se side. Signed X Title: Date: Date: FOR ART T �J Application Accepted by" ate real Pit or Grout Inspection by Date Final Inspection b Datef� Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health-Permit/Services 1601 E. Hazelton Ave., P O_Ikx 2009, Stockton, CA 95201FEE F INFO AMOUNT DUE AMOUNT REMITTED CAS RECEIVED BY I�DATE �] PERMIT'N0. fy� + EH 13•24 IIiEV.I/H SIT6 17 EH 1446 I t