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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH. SERVICTS 1601 E ENVIRONMENTAL AVE. , PHONE (209)468-3420 TH P O BOX 2009, STOCKTON, CA 95201 �F07 EMIT EXPIRES 1 YEAR FROM DATE ISSUM �0 �J990 (Complete in Triplicate) y/',1� made to San J uin Count for a permit to construct and/or install. the work h�ere�F�s,, embed This Application is hereby ith y Mr / application is made in compliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Re Ifo San Joaquin County Public Health Services. Jab Address /v 3 3 e_ E City— ��G� ^� Lot Size/Acreage - - ---x '�-- -*-- � . Owner's Nams J. Addre R44—mss ;` Phone 3663 4nfk-c fir., -5.11 Contractor ��/�•� /�I G t-- Address A� c a 9 .2 o 04 License No.&Z_ `/d Phone lad/ ' fV TYPE OF WELL/PUMP: NEW WELL NO WELL REPLACEMENT ❑ DESTRUCTION ❑ out of Service Nell PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FED. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS l� i I-] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation _ Z Dia. of Well Casing Cl Domesticl Private R;rGrovel Pack ❑ Tracy Type of Casing evc Specifications I"l Public (.1 Other n Delta Depth of Grout Seat 3 6,164 Type o I I Irrigation S Approx. Depth t t Eastern Surface Seal Installed by L 6R Repair Work Done L] Type of Pump H.P. State Work Done w Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Materia]. & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAiRlAODITION I I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.l Installation will serve. Residence— Commercial_ Other Number of living units: Number of bedrooms Character of&oil to a depth of 3 feet: Water table depth X, SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal ~ Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line 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 i rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: 1 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 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." The applicant must�call for all required inspections. Complete drawing on reverse side. �/ 1 Signed x I]� ` /7 _ s Title: 1/-: •t�.� Sc.L:T��, Date: FOR DEPARTMENT USE ONLY q � Application Accepted by r] Date r I Area Put- Pit or Grout Inspection by �"`� Date ! r Final Inspection by r — Date r Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave.. F 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK 8 CASH RECEIVED BY DATE PERMIT-NO. INFO EH 13 24 IREVI ENA'25 no 4