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APPLICATION FOR PERMIT L' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOR 2009, STOCKTON, CA 95201 � l1 RERMIT EXPIRES I YEAR FROM DA ED (Complete in Triplicate) Application is hereby made,to San Joaquin County for a permit to construct and/or install the vork herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. ^� �� 4�{!�r Job Address JS � JI{�h� � City r aLot Size/Acreage Owner's Name zaam -1��`/C 5400 �� Addr, A== aI o pe_ - Phonez-Of FO 01M 1�4�o�III W-2yarw �14o / e-57 X 37zli79W Contractor �� dress +c ki ..i44c_ e. 9�[- License No. Phone TYPE OF WELL/PUMP: NEW WELL R/W- WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION J0 SYSTEM EPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK>/00 SEWER LINES ZO 'Sim DISPOSAL FLD, = PROP. LINE _ FOUNDATION AGRICULTURE WELt>209 OTHER WELL PITS/SUMPS T ... INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS iE �++das r ❑ Open Bottom C7 Manteca Dia. of Well Excavation Dia. of Well Casing C7 Domestic/Private Gravel Pack Tracy Type of Casing it Specifications r JIB Public II114094A)r• (-1 O'her n Delta Depth of Grout Seal 3 Type of Grout t I I Irrigation �&.Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done L7 Type of Pump H.P, SatIF Wo k D ne �s Well Destruction ❑ Well Diameter Sealing Material & Depth ) Y S Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) 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 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest. Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation ,^„_ Property Line DISPOSAL PONDS ❑ 1 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: "I certify that in the performance of the work for which this permit is issued, l 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 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. , �C r Signed X !+ fil.�� Title: /'e_I QLd'+l�l�V 772 Date: 3� FOR DEPARTMENT USE ONLY Application Accepted by Date GE—K-�Jf Area `f 3 Pito rut spection by Date� Final Inspection by - rDate Additional Comments: Applicant – Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 ox 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERM/17 N0. a EH A-2 tREV. 35 -319-3S {'_3S _ 7��q a�„ I P-D EH 2I-26 l jj 7 W 1 ,� 1!