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- a APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. ,- PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 ESP RES 1 YEAR FROM DATE ISgUED (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. l Job Address #:() + ; -� j'� City's - Lot Size/Acreage I�^ 1 f f ��: , i• �C':Ihone mac` i - ,� Owner's Name I` ( L Address ,.If r' • _ /�.' �`01 (�License No �i k 7 Phone `�ti Contractor %� Address ' �W -- TYPE Of WELL/PUMP:. NEW WELL Li"— WELL REPLACEMENT O DESTRUCTION O Out of Service Well ❑ PUMP INSTALLATION Lam' SYSTEM REPAIR ❑ OTHER O Monitoring Well � I DISTANCE TO NEAREST: SEPTIC TANK [-1 SEWER LINES DISPOSAL FLD. PROP. LINE-19-2 ` FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE- TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t E Industrial CAI,Open Bottom C1Manteca Dia. of Well Excavation Dia. of Well Casing CYIX'omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications -- f'i Public Cl Other fl Delta Depth<of Grout S I Type of Grout- I I Irrigation —,.Approx. Depth I I Eastern Surface Seal Instal f Repair Work Done 0 Type of Pump / H.P. _ State Work Done ; Well Destruction ❑ Welt Diameter Sealing Material & Depth f, Depth Filler Material & Depth A\ V TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION'I I DESTRUCTION I i INo septic system permitted it p ublic sewer is available within 200 feet.) I 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. O P Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total.lengthlsize ' c FILTER BED ❑ 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 I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state Iaws, and-. ti rules and regulations of dhe San Joaquin County }- Hom6 owneTi5-r'licerised`apenF`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." I The applicant must call for all required inspections. Complete drawing on reverse side. Signed XTitle: : i . s-. ct.�.t Date: C� i TMENT USE ONLY C � Application Accepted by Date ^' 1- _' Area i Pit or tr ut Inspection by inal Inspection by 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 CK RECEIVED BY DATE PERMIT'NO. INFO CASH f r0� 1 1I 3 � 3 2� g7-V-�at2 13 . EM -24(149V,I 18 5) - EH 14.26 ,.