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APPLICATION FOR PERMIT (5 Lb 1 , 0� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES W? j1 ENVIRONMENTAL HEALTH DIVISION eFCbx D 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOC%TON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED_ (Complete in Triplicate) Application is hereby made.to Sm 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 HealthServices.f I /L Sc' !k.}' Ci �_%��_ Lot Size/Acreage ( Job Address ry Owner's Name AddressPhone .E�T7t_ c+ ( S•-%�/r.I ,Phon��> Contractor � C \ .�tn"� Address Sr^7�Cf L ,��Fh"��flicense No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 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 F.1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. o/Well Casing I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications PI Public ❑ Other Il Delta Depth of Grout Seal Type of Grout — I I litigation _.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material & Depth ` w, Depth Filler Material a Depth V_ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADOITION)F DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: I Number of badroom; _ Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line t1�^ vl LEACHING LINE ❑ No. & Length of lines '— 3 -- Joist 1pgth/size FILTER BED LI Distance to nearest: Well 61 r Foundation O Property Line�1 SEEPAGE PITS 1 I Depth Size Number _ SUMPS LI Distance to nearest: Well In"i 'Foundation 1 Property Line ti 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, 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 shell employ persons subject to workman's compensa tion lawn of California." The applicant call r al ills ree-&- spec ions. Complete drawing on reverse side. Signed X '-��'Z2Z.�Gq'1".y Title: f2.'i'z'f-�-'`— Date: d F DEPARTMENT USE ONLY U Application Accepted by �� Date Area i 7i !!)to lt r Grout Inspection by �� Date .��inal Inspection by�� Data _ °[� Additional Comments: Applicant - Return all copies to: San Joaquin Crounty Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 ' FEEJ AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO . EH 13-24 IREV.I/nal EH`.61e