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APPLICATION FOR PERUIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 4511 ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FRB DATE ISEUED (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 �' CityrSi OCC` J-J Lot Size/Acreage Owner's Name G DrLo/•Cadress mgPhone Contractor i�Jr Ta-JFK dress a-7 g�D6R:D6�z,, License No. -76� Phone � 3sZ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ ,,,-DESTRUCTIONt of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR-[- _. 1;1,r•'~ OTHER p Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK Nor- SEWER LINES ZOSO t 4- DISPOSAL FLD. PROP. LINE ©� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ' �' I i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i C-} Industrial ❑ Open Bottom ❑ Manteca ` Dia. of Well Excavation- Dia. of Well Casing f] Domes00Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications I') Public (.1 Other Cl Delta 4 Depth of Grout Seal Type of Grout I 1 Irrigation 1 — Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done v Type of Pump H.P. `State Work Done _ Well Destruction Well Diameter Sealing Material & Depth t Depth U Filler Material & Depth 1 " TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is I available within 200 feet.) Installation will serve: Residence— Commercial,Y... Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: I Water table depth r I SEPTIC TANK. ❑ Type/Mfg Capacity No: Compartments- PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line J LEACHING LINEI ❑ No. & length of lines Total length/size FILTER BED '` C] Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number ""*-- SUMPS L) Distance to nearest: Well Foundation . Property Line j i DISPOSAL PONDS ,a 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 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, 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 t call tor II required i pections. Complete drawing on reverse side. ` Signed + Title: -- Date: FOR DEPARTMENT USE ONLY r Application Accepted by Date 1J Area yy� l Pit or Grout Inspection byDate Final Inspection by 1` ' ' f' Date Additional Comments: "r W e�Q rte,�_,5 [�� (�G! -Kecp -- Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMITN0. INFO CASH j g� 7 . EM 17-211REY.I/N5l FAV �� - [�� [ "� .W x-17? h EH ti•2e