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{ APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOR 2009, STOCgTON, CA 95201 ENV1 �� r 7 ,��I F p"IT E%PIRE 3.1 YE R FR MDA �E NMENTAL (Complete in Triplicate) ERMITISER& n � L iW This Application is hereby made,to San Joaquin County for a permit to construct and/or install the work he descr 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. � + Lot Size/Acreage!f City Job Address L Owner's Name Address }� ! /I r7 �^ �ss�y L� 11`1C17��—L� - G . License No. Z ZZ`e—Phone��d U 11 0Contract r _..��_-,—.,-. I NEW WELL ❑ �' WELL REPLAGEMENT ❑ DESTRUCTION Ll Out of Service Wedl TYPE OF WELL/PUMP: = OTHER D Monitoring Hell �� PUMP INSTALLATION C/- t, '? SYSTEM REPAIR 0 ! DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SfWER�INES PITSI5UMPS M1y FOUNDATION AGRICULTURE WELL OTHER WELL {,f INTENDED USE TYPE OF WELL PROBLEM AR,EA CONSTRUCTION SPECIFICATIONS �. { 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing f�i Industrial P Specifications � - Cl Domestic/Private CI Gravel Pack L7 Tracy Type of Casing Type of Grout V ' I'1 Public is Other [-1 Delta Depth of Grout Seal I ( Irrigation _ _,.Approx. Depth _ I I Eastern _T Surface.Seal.installed by r Repair Work Done 0Type of Pump H.P. State Work Done �ti iy.-. Sealing-Material aDepth y Well Destruction 0 Well Diameter � f f,- � � ) f Depth F =2=-% ller Material-&'Depth I -TYPE OF SEPTIC WORK: NEW INSTALLATIONTI I REPAIR ADDITION_ DESTRUCTION I I ofvailable septiwshit m reined if public sewer is Installation will serve: Res'dence Commercial_ Other Number of living units: Nurinber_of- drdoms I� Water table depth Character of soil to a depth of 3 feet: F SEPTIC TANK © Type/Mfg Capacit -`� No. Compartments y 4� Method of Di sal , C, PKG. TREATMENT PLT. D I Distance to nearest: Well Foundation"— 0 _Property Line LEACHING LINE Ll No. &Length of lines Tntak length/size FILTER BED ❑ Distance to nearest: Well� Fo nu dation _ tr� Property Line_ SEEPAGE PITS Depth f5ize � N mbar SUMPS LI Distance to nearest: Well J�LJ - Foundation' Property Line . i DISPOSAL PONDS ❑ _ - - I ftereby certify that I have prepared this application and that the work will Lie done in Wed8rdance with San Joaquin couniy-,rdirt nces, state laws, and rules and regulations of the San Joaquin County I 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,di sub-contracting signature certifies the following: "!certify that in the performance o`f the work�or w—H]Eh'this permit'issued; I shall Hmploy persons subject-to workman's compensa- tion laws of California." The applicant call for a r uir inspections. Complete drawing on reverse 'de Signed X Title: Date: FOR DEPARTMENT USE ONLY - c Application Accepted byr-- Date r 4 �— 1� Area r� i i� Grout Inspection by Date �� Final Inspection by Data [, Additional Comments: Applicant - Return all copiesito: 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 CK RECEIVED BY DATE PERMIT NO. INFO I CASH 1 � + EH 13-2IREv,I I K 51 �1 L1- C - O-ZS.s LA EH 4 , ! y