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A V i APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION �1 W� 1601 E. HAZELTON AVE. , PHONE (209)468-3420 r"4 P O BOX 2009, STOCKTON, CA 95201 EXPIRES 1YEAR 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 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. 09� VJob Address kJ +O+! . 4City Ar Lot Size/Acreage Owner's Name �Q1HR1 //c a%s".r / q dress Z8�r 735 Phone .4014y 1441 �yQ, 'rte ! c57 O Contractor cess am / License No, Phone T 7Z TYPE OF WELL/PUMP: NEW WELL (_g WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION [�7 SYSTEMA E AIR ❑ OTHER C Monitoring Well DISTANCE TO NEAREST: SEPTIC TANKy- ..� SEWER LINES DISPOSAL FLD. r" PROP. LINE 2a FOUNDATION 1J22_L_ AGRICULTURE WELLAOML OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS S M Industrial ❑ Open Bottom Q Manteca Dia. of Well Excavation+ Dia. of Well Casing (_I Domestic/Pri�j-e X Gravel Pack K Tracy Type of Casing G Specifications rttl Public NW+u7ol D Other n Delta Depth of Grout Seal 3 Type of Grout_ I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L7 Type of Pump H.P. rSt to W rk D a_ Well Destruction ❑ Well Diameter Sealing Material & Depth / Depth Filler Material & Depth 4 f 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. ❑ 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 n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state Iaws, 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 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 II fo alt required inspections. Complete drawing on reverse side. ��j, Q/ Signed r Title: 1F'-F21 Date: v !� FOR DEPAR MENT USE ONLY Application Accepted by a Date = Ars,Pit Grou! spection by Date G ' eFinei Inspection byDate G Z�' Additional Comments: Applicant – Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO CASH RECEIVED 9Y DATE PERMI7'NO. r EH Q-24{REV.I/N S) �'0� 1 j p,3! -39-00 ,+1 f EH A46 �' _�o