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t - APPLICATION FOR PERMIT P 4 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES } ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PEMIT EXPIRES 1YEAR FROM DAIS ISSUED (Complete in Triplicate) t 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 L ` Ci � Lot Size/Acreage Owner's Name ___ ____ Address Phone Contractor Address License No. ZJ aL l*ne k r. TYPE OF WELL/PUMP: _ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring'Well C� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FL•D. PROP. LINE \\ ' FOUNDATION „,AGRICU.LTURE.WELL_ OPWER WELL'^""'^•- -PITS/SUMPS a INTENDED USE TYPE Of WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j ❑ Industrial ID Open Bottom ❑ Manteca Dia zof-Well Excavation 1# ) Dia of Well Casing fa Domestic/Private ❑ Gravel Pack 0 Tracy i Type of,.Casiirg ' Specifications C1 Public CI Other 11 Delta � Depth of G'roui Seal; � � Type of Grout I i Irrigation Approx. Depth I 1 Eastern # Surface Seal Installed bye" 4 I Repair Work Done LT Type of Pump H.P. -- State Work Done (� Weil Destruction ❑ Well Diameter Sealing Material & D'epth Depth A leMatfrial,b Depth ` s TYPE OF SEPTIC WORK: NEW INSTALLATION'I I', REPAIRLADDITION ,DESTRUCTION-I I_(No septic system permitted it public sewer is (� t p " a I available within 200 feet.) Installation will serye: Residence Comm¢rcial— Other i� Number of living units: I Number of bedrooms Character of soil to a depth of 3 feet: .. � ,,,,_ 1 Water de table pth 06 SEPTIC TANK. ❑ Type/Mfg QW>1-�e�7 %„__. Capacity 0 d No. Compartments �^ i PKG. TREATMENT PLT.❑ - ) Method of Disposal Distance to nearest: Well I ; Foundation Property Line S'' f i f LEACHING LINE 4❑ No. & Length lines / 9 ./�,/r�,.�,.sTotal length/size fFILTER BED ❑ Distance to nearest: Well Foundation ZZ2 r Property Line /Q � O SEEPAGE PITS ;,I I Depth -Size-.- -.-_:.._ Number. ` SUMPS k;J1 Distance to nearest: Well Foundation ' Property Line DISPOSAL PONDS �0 -"Y' 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 IN - 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 taws of California.”Contractors 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 California." s The applicant call f_or It req ' d in pections. Complete drawing on reverse side. G� Signed X Title: Date:—/- - FOR DEPARTMENT USE ONLY Ap tion Accept by D t_ x d✓ Area_1 j �r6 tspection by Data-• �- -Final Inspection tion —_ ate ---- ` Additional Comments: s Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 4 1601 E. Hazelton Ave., P 2009, Stockton, CA 95201 FEE i AINFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. i + EH -211HtY.l�xS, zz� I 1� n t � EH t1.26 l !V 4v