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APPLICATION FOR PERMIT - SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 95201 PEMIT EXPIRES 1 YEAR EROM 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 application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address �GSSS �' V0. ��'�ty"'^ --- - --- City Lot Size/Acreage Owner's Name�aLfLINI?./'S�C` Address Phone 9?,Pf ff35013 /40/ /sy Contractor wrx+ r"`�" I Address / License No.�S- S�� Phone 1613AZW�iW TYPE OF WELL/PUMP: NEW WELL ® 14W-7—WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION �] SYSTEM PAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK etlQV SEWER LINES © DISPOSAL FLD. PROP. LINE FOUNDATION 100 AGRICULTURE WEL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICA IONS u n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r_1 Domestic/Private I Gravel Pack Ile Tracy Type of Casing Specifications - )4 Public&rrt[T4W_ 1-1 Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation �-.. Approx. Depth t I Eastern Surface Seal Installed by Repair Work Done L] Type of Pump _ H.P. Stat W k e Welt Destruction ❑ Well Diameter Sealing Material & Depth !G Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION [ 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. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Ll No. & Length of lines Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 11 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 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 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 t r all required insPections. Complete drawing on reverse side. r Signed X_m__ (ryt t, ,L� Title: Date: g0 FOR DEPARTMENT USE ONLY Application Accepted by — 1.• e�Y- _ __ -_--_- - Date /J Area y D Pit or ro Inspection by Date 62710'V0 Final Inspection by_-_+ __ r,ta Date Additional Comments: Applicant - Return a.a.l, copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P PAOX 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CpASH RECEIVED BY DATE PERMIT'No. a EH 11-24(REV.1/R5I ,/J J �O �S �O 20�� &_f3't7 1q0-)4Y1 EH -2a