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. . . APPLICATION FOR PERMIT I . SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 EXPIRES 1 YEAR FR!2M DATE (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 Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County public Health//Services. Job Address I')- eqln rS*tPfLy!, ,_ City G Lot Size/Acreage Owner's Name __ _T�/2 C�rru .ri it'r/ � .* Address Phone Contractor � Address /� Ci License fVo, '3 Phane TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well ❑ 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 0 Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing D Domestic/Private ❑ Gravel Pack C3 Tracy Type of Casing Specifications VI Public Cl Other n Delta Depth of Grout Seal Type of Grout I I Irrigation w.Approx, Depth t I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATIO REPAIR1ADDITION I I DESTRUCTION 11 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence� Commercial— Other Number of living units: --/— Number of bedroom Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. 0 Type/Mfg L- Capacity v-� P No. Compartments PKG. TREATMENT PLT. ❑ .1��7- T Method of Disposal Distance to nearest: Well Foundation C � Property Line—C _ r LEACHING LINE ❑ No. & Length of lines Total length/size ' FILTER BED ❑ Distance to nearest: Well Foundation _3c�,It�_ Property Line SEEPAGE PITS 11 Depth Size Number SUMPS 19 Distance to nearest: Well O-f Foundation property Line DISPOSAL PONDS El I hereby certify that f 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, 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 issuid, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all equired inspections. Complete drawing on reverse side, �J h Signed K Title: Date: FOR.DEPARTMENT USE ONLY Application Accepted by Date 79#ti lqlArea �� Pit or Grout Inspection by Date Final Inspection by 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 MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMICK 2 7'NO: . EH 13-24(REV.rinS) EH 144-20