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APPLICATION `FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601' E. HAZELTON AVE, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DAT " .$SUED (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..51+9 and 1862 and the Rules and Regulations of San Joaquin County Public He'a]lth Services. n„ n Job Address ' f j +� d� �' City C/V- V1 Lot Size Acreage _45 GV ON-0 V\G 2,q C Owner's Name i Address {� �l Contraclos6f*JVtAc��ti`^ Address Z License No. Phone 'l�Z TYPE OF WELL/PUMP: NEW WELL.❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well Ll. PUMP INSTALLATION C7 SYSTEM RE5R 0 OTHER ❑ XMonittoorinngg Well DISTANCE TO NEAREST: SEPTIC TANK ��`�, ��SEWER LINES .- DISPOSAL FLO.UK' "t-'SOP. LINE FOUNDATION n�AGRICULTURE WELL t C+0+0�OTHER WELOt � ITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic rivets 0 Gravel Pack ❑'Tracy -- Type of Casings LC A G Specifications l'I Public XotherAjt) 6m^f- I1 Delta Depth of Grout Seal — y Type of Grout W I I Irrigation 6& Approx. Depth I I"Eastern Surface Seal Installed by 411 Repair Work Done 0 Type of Pump H.P. nQh� State Work Done Well Destruction O Well Diameter Sealing Material & Depth i Depth Filler Material '& Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I. DESTRUCTION Irl fNo septic system permitted if public sewer is I� available within 200 feet.) 1 I Installation will serve: Residence_ Commercial Other W. 11 �u Number of living units: Number of bedrooms Y. „ . � h. table�- '"- Character of soli to a depth of 3 feet: Water depth SEPTIC TANK ❑ Type/Mfg "- Capacity No. Compartments PKG. TREATMENT PLT. ❑ Y _ s Method of Disposal: f Distance to nearest: Well Foundation Property Line _ + LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED EJ Distance to nearest: Well Foundation .Property Line ` SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS © w 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 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, 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." t The applicant TU61 call forre ui edinspttc � ns. Complate drawing on reverse side. Signed 0— .Title: -e 0 �� Dater ., s FOR DEPARTMENT USE ONLY Application Accepted by Date .// 7 g Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return a].1 copies to: San Joaquin County Public Health .� Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 A. 1 FEE AMDUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO t EH13-24(REV,I/n 51 Vol J (r e)0 � !' (�� 7CJ� � /I�'�'� �./ �Q'� ✓ EH ,26