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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIROINMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE., PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 pMIT EXPIRES s YEAR FROM DATE ISSUED (Complete in Triplicate) Application 1s hereby mnde,to San Joaquin County for a permit to construct and/or install the work herein described. This sppllestion is made in compliance with San Joaquin County Ordinance Ho. 549 and X1862 and the Rules and Regulations of San Joaquin County Public Health Services. e -Di !i!9 / /h Y T_ L -.__L. 1! . crime /e,..... on A0 Job Address 777,9 Z. /LP ury X . ES12LL daL5 Address S' fit.-e-Phone�O /' 9JlOS Owners Name / / � n 'r� Contractqow r"md Address d7�' N• L4rlCO 1^3 License No. 7_1- Phone �a� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT M DESTRUCTION &Pr Out of Service Well PUMP INSTALLATION ❑ SYSTEM REPAIR 11OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE — FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USEPE_ OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Indurial OPeee Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing st Fl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications [A Ptadic 17 Other fl Delta Depth of Grout Seal Type of Grout 1 I Initiation—Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work D" Weg Destruction Well Diameter — Sealing Material A Depth it Depth >_L_ Filler Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I I IN septic em s�;�itted it Public sewer is 1 within Installation well serve: Residence — Corrimerasl — Other Number of living units: _ Number of bedrooms Character of will 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 LEACHING LINE ❑ No. g Length of fates Total length/sue FILTER BED ❑ Distance to nearest: Wen Foundation Property Line SEEPAGE PITS I I Depth Six Number SUMPS LI Distance to neerost: Wen Foundation Property Line onunc n S f tr. P" 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 certlfwn the following: "1 certify that in the performance of the work for which this permit is issued, 1 shag 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, 1 shall employ persons subject to workman's compensa- tion Laws of California." The appFcall for /�./ ned inspections. Complete drawing on n raves side. p Signed w —V ?ra -cvs Title: �-`� - Date: O - U- R DEPARTMEM USE ONLY A b�'� _... Date Z� Area n 1- Application Accepted by Data Pit or Grout Inspection by Date Final Inspection by Additional Comments: _ Applicant - Return all copies to: San Joaquin County Public Health Services, Ravirommental Health Permit/Services 1601 H. Hazelton Ave.. P O Boz 2009. Stockton. CA 95201 FEEAMOUNT DUE AMOUNT REMITTED CASH I CENED By DATE PERMIYNO. INFO