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ii APPLICATION FOR PERMIT ' Z F l SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION >r 0 C� 1601 E. HAZELTON AVE. , PHONE (209)468-5420 P O BOX 2009, STOCKTON, CA 95201 { �f HERMIT EXPIRES i YEAR 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 trade in compliance with San Joaquin County Ordinance No. 549 and 1562 and the Rules and Regulations of San f Joaquin County Public Health Services. Job Address City x0-4t: Lot Size/Acreage I� i Owner's Name D r l t E��C/ Address��7 1042 Phon -�06 1, 4 Contractor )3,&;7,L r Address 5Q Csr-� � License No/ d 137Phon TYPE OF WELL/PUMP: 11. NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION © SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well D DISTANCE TO NEAREST: SEPTIC TANK d SEWER LINES f D 6 r DISPOSAL FLD. PROPLINE FOUNDATION 146 AGRICULTURE WELL -S'a-L OTHER WELL .�0 I PITS/SUMPS INTENDED USE TYPE OF WELLi , PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial 00!pen Bottom`., ❑ Manteca Dia. of Well Excavati Oia. of Well Casing if �T>(Oomestic/Private (Gravel Pack 0 Trac T r Q � y Type of Casing Specifications -�. 4 f'J Public fa Other f� Delta Depth of Grout Seal160 Type of Graut `�u�L.', I i Irrigation �'.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done �f Well Destruction ❑ Wefl Diameter Sealing Material 6 Depth t Dep tlh Filler Material & Depth 1 +' - TYPE-OF.-SEPJ.IC_WDRK:-.,.NEW-INST-ALJ+-4T40N,.1-J--.R£P.A UAADDITION-d-I,.pESTRUC-TJO+Y J-\I. ( Yo-septic-system permitted if public sewer is I i' available within 200 feet.) f Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms t € Character of soil to a depth of 3 feet: Water table depth ` SEPTIC TANK ❑ Type/Mfg Capacity No. Com3partments PKG. TREATMENT PLT. ❑ Method of Disposal E D`stance to nearest: Well Foundation Property Line ) 4 --LEACHING LINE Cl . No. & Length of lines Fst , length/size t Total len g q 1 FILTER BED t] Distance to nearest: . Well Foundation Property Line SEEPAGE PITS 1 1 Depth ` Size __ Number SUMPS LI Distance tro,nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I I hereby,certifyhat I have prepared this application and that the wock will be done in accordance with San Joaquin county ordinances, state laws, and rulas and regulations of the.San/Joaquinycounty I Home owner or-' eine ed agent's signature certifies the following: "I certify that-in the performance of the work for whlch this permit is issued, I shall not employ any person in such rnanner as,ta become subject to workman's compensation laws of California," Contractorfs hiring or sub-contracting signature certifieii 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 Calif rnia." t The applicant u cal or all re' it d ins Ii pections. Complete drawing on reverse side. Signod,` r Title: Date: R DEPARTMENT USE ONLY c - � t Applicationt Accepted by Date .__._ Area r-- 4 Pit rout I ction byr Data Final Inspection by Date f d Additional Comments: � Applicant Return all copies t San Joaquin Co ty Pub is Heal h i 11° Services, Environmental Health Permit/Services 1� 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0, EH 13-24 IAEV.iixssEH 14-20 1Ee2 i II .