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R APPLICATION FOR PERMIT SAN 30AQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEAL, H DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 EXPIRES 1 YEAR ROM DATE JUVED (Complete is 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 110. 549 and 1862 and the Rules end Regulations of San Joaquin County Public Health Services. rtir^�+S.dc e' city Address AAUkLot Size/Acreage Owner's NameE�Mr,L` ., ��'....... ....._.,.__ Address? • ter �� rTb�' i Phon �`�r7 4-L vr-kA Contractor '�T f. �N' t Address L . ra a License No(�li U4 Lel Phon At -17 ri�' %y TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEN ENT n DESTRUCTION P Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well ,i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing C] Domestic/Private 0 Gravel Pack C1 Tracy Type of Casing Specifications � I-1 Public f7 Other fl Delta Depth of Grout Seal Type of Grout .[ I I Irrigation Approx. Depth I I Eastern Surface Seal nstalled by Repair Work Done IJ Type of Pump H,P. State Work Done Well Destruction Well Diameter Sealing Material i ept �4% ; ( Ftfr. ZCc; I'f^,e1%' , Tra[ r t' Depth-- _ -yQ,;rsk' Filler Material L Depth As r$-,,Jf✓ TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIR/ADDITION t I DE TRUCTION l 1 (No septic stem permitted if P V P public sewer is available within 200 feet.i Installation will server 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 Capac ty No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 Home owner or licansed 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 workmen's compensation laws of California." Contractor's hiring or subcontracting signature certifies the following: "I certify that in the performance of the work for which this PGM kit is issued, I shall employ persons subject to workman's compensa- tion laws of California." I The applicant must 11 for all required inspections. Complete drawing n reverse sid . Signed 1t , `it(� Title: i � w kv, d J Date: FOR DEPARTMENT USE ONLY [�t61 �., Application Accepted by r Date�1` fh- Z Area �� j^7IV, , rL _ Pit or Grout Inspection by [.'N" " ' Date f �' Final t spection by ry Date rI !! 2 Additional Comments: r Applicant - Return all copies to: San Joaquin county Public Health Services. Ravironmental Health Pe t/Services 1601 E. Hazelton Ave., P 0 Box 200 . Stockton, CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERmrruo. . EH,3.2,(REV.,/X sr D D oo A/-A/ EH t4.20