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APPLICATION FOR PERMIT SAN. JOAQUIN COUNTY PUBLIC HEALTH SERVICES I ENVIRONMENTAL HEALTH DIVISION 11 160X_,.'E. HAZELTON AVE. , PHONE (200468-3420 P O BOR 2009, STOCKTON, CA 95201H PERJMIT RES I 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 i application is made in compliance with San Joaquin County Ordinance No. 549 and 1$62 acid the Rules and Regulations of San Joaquin County Public Public HHeealth Services.s �+J � Lc e. Cit ' Job Address rrf y r� Qdf of site/Acreage Owner's Name n 12,W Address - ' I Phone Contractor t� Address- 1rDU !2OX 1 License t��:�7� r�- Phone f TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service well ❑ f i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well C7 i i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE y FOUNDATION. ..AGRICULTURE WELL.—.OTH E8 WELL1r _PITS/S,UMPS_____ µ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F] Industrial ❑ Open Bottom © Manteca Dia. of Well Excavation II Dia. of Well Casing y p I I Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications -- FI Public 17 Other Ll Delta Depth of Grout Seal I Type of Grout I I Irrigation —.Approx. Depth l I Eastern Surface Seal Installed by �I Repair Work Done L3 Type of Pump H,P. State Work pone _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material i Depth �H TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/-ADDITION I I DESTRUCTION i I INo septic system permitted if public sewer is y available within 200 feet.► Installation will serve: Residence Commercial_ Other Number of living units: —I— Number of bedrooms Character of soil to a de�pthh f 3 feet: s�d 11; �} Water table depth I SEPTIC TANK. Td' Type/Mfg G �capa��cy o. Compartme11 . knts PKG. TREATMENT PLT,❑ ! ethod of Disposal t s Distance to nearest: Well ` Foundation Property Line F LEACHING LINE fCr No. & Length of linesTotal length/size FILTER BED ❑ Distance to nearest. Well!+ Foundation _ „� Property Line - r ;II! I SEEPAGE PITS A-I' Depth Size . Number SUMPS LI Distance to nearest: Well [�� `Foundation `_ Property Line DISPOSAL PONDS ❑ k hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county nidinances, state laws, and ' y rules and regulations of the San Joaquin County 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 nt f employ any person in such manner as to become subject to workman's conipensalion laws of California." Contractor's hiring or sub-contracting signatur r i 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 comripensa ` tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. f' = Signed X___4 I,le: ....��Q�`lt ji . . Date: FOR-DEPARTMENT_USE_ONU r--� _ )a-" h -tety Area 2_ "r Application Accepted by —___-___ _ Date 11' - S Pi rou I speclion b 'C� Date 1 —(n U-4inai_Inspection_by--U I �' , Date 1177 Additional Comments: Applicant -- Return all copies to: San Joaquin County Public Health t Services, Environmental`Health Permit/Services` 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 915201 FEEK 11 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED t3Y II DATE PERM17'�NO. . EH13-24IREV.1/h5) too 1.r �� ' F I�� i0 Jo -�2 EH 11.26 1