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APPLICATION FOR PERMIT ; SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE4„-V„ } ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-34120 ` P O BOIL 2009, STOCKTON, CA 95201 E!BUIT E%PIRES 1 YEAR FROM .DATIsI3 • ED- (Complete in''Triplicate) c•t 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 a Joaquin County Public Health .Services. T Job Address 0 • ”j R �y City t r Lot Size/Acreage Owner's Name W �ittwl (it 7t — _ Address JA/A9 _ Phone - y�6� Contractor t! r" - __ Address- V-- --�7 �•License_No��3U S --_phone r 7� TYPE OF WELL/PUMP: _ r NEW WEL WELL REPLACEMENT CJ DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATIONS SYSTEM REPAIR ❑ OTHER C7 Monitoring Well t DISTANCE TO NEAREST: SEPTIC TANK s20 + SEWER LINES DISPOSAL FLD. 20 - PROP. LINE ice_ FOUNDATION AGRICULTURE WELL OTHER WELL3•.a0 PITS/SUMPS ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C1 industrial ❑ Open Bottom © Manteca Dia. of Well Excavation _ 1. _ Dia. of Well Casing pomesticlPrivate �I Gravel Pack ❑ Tracy Type of Casing /` yC Specifications Cl Public 1-1 Other n Delta Depth of Grout Seal /C3C7 Type of Grout C«Qr1 I Irrigation tam Approx.el6epth I I Eastern Surface Seal installed by Repair Work Done L3 Typeyof Pump; St+ H.P. State Work Done A Well Destruction ❑ Well Diameterw Sealing Material & Depth Depth p 1 a Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION ( I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) 3 4 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 t SEPTIC TANK © TypeIMfg Capacity -- No. Compartments r PKG. TREATMENT PLT. C1 Method of Disposal Distance to nearest: Well Foundation Property Line ' LEACHING LINE: D No. & Length of lines Total iength/size- FILTER BED ❑ Distance to nearest: Well Foundation Property Line. SEEPAGE PITS I I Depth i Size + Number { SUMPS LI Distance to nearest: Well Foundation Property Line t L; DISPOSAL PONDS ❑ ! I hereby certify that I have prepared tliis 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 - ance of the work for which this permit is issued, k shall not Home owner or licensed agent's signature certifies the following: "I certify that in the perform 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." r� The applicant must call for all required inspections. Complete drawing on reverse sides Signed X ��`- Title: 'V k *� Date: 3 92 OR TMENT USE ONLY � P Application Accepted by Date v Area Pit or Grout napection by Date3 Final Inspection by Data_ l � C +� 'If (ntt � [t S 1D Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Pp op Services, Environmental Health Permit/Services ' 1601 E. Hazelton Ave., P x 2009, Stockton, CA 95201 ,L1 _ Ix FEE AMOUNT DUE AMOUNT REMITTED GSH RECEIVED BY � DATE PERMIT.NO, � INFO } r� `� q y Lfu_ . EH 13-24 tREN.+i w 5l 7 �! ll �'i•-� L/*� L-�� T I �� (J '-' � � EH t�•2B ^