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APPLICATION FOR PERMIT t-C ►� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES V� ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 W;// f)U [ P O BOX 2009, STOCKTON, CA 95201 . PERYIT EXPIRES 1 YEAR PRO G-DATE__ISSUPD -e°ij 'f"� (Complete in Triplicate) �b 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 1662 and the Rules and Regulations of San Joaquin County Public Health Services. �JJJ r_ P y Job Address 14a N. n fly Pol' City y a Lot Size/Acreage 4 Owner's Name `� ' � Address b as 9PN. Tu +- o t Phone 1- �� a�►�� Contractor __Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION C1 Out of Service Well Ar PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIfICATiONS ` n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing «,. 17.1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'I Public E7 Other n Delta Depth of Grout Seal Type of Grout - I I Ifrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done Ll Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I I DESTRUCTION I I lNo septic system permitted if public sewer is available within 200 feet.) . Installation.will serve: Residence_ Commercial_ Other N7tt� r of living units: Number of bedrooms s Character o to a depth of 3 feet: Water tab) Z'th „ SEPTIC TANK. Type/Mfg Capacity No. partments PKG. TREATMENT PLT.❑ ethod of Disposal '�C)istance to near. Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines — Total length/size I. FILTER BED 0 Distance to nearest: Well undation '- Property Line - - 4'' 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 laws a -711 LAM 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 issuedjshallnot employ any person in such manner as to become subject to workman's compensation laws of California.” Contractor's hiring or sub-contractincertifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman'stion laws of California." The applicant ust tali for all re uired inspections. Complete drawing on reverse side.)It Signed X Title: Date: '�o FOR DEPARTMENT SE ONLY Application Accepted by e 2- .hen Sis&a o. . Date__ �"3 l l Are �5L Pit or Grout I epection by Date Final Inspection by ate , Additional Com e 7G y j Applicant - Return, copies to: San Joaquin County Public Healthy Services, Environmental Health Permit/Services 2l' 1601 E. Hattelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE -PERMIT'NO. + EH 13-24(11EV.f i K sl wo .c)r-> ,nr'1 '2f'C'Q �r 1 EH 14•25 l.tl�-' ffff I �.7•-a L i.