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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 DATE ISSUED (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. 549 and 1862 and the Rules and Regulations of San Joaquin County Publics Health Services. ///� Job Address /U / o/�/�f7p/! M City Lot Size/Acreage Sf" �' L Owner's Name Address �� / / y � �� lu_/'�-� Phone 3 .3.3- Contractor E I( kl)_S6 ddress :363 License No"S Phone Ut1 TYPE OF WELL/PUMP: NEW WELL E J WELL REPLACEMENT O DESTRUCTION L Out of Service Well O r_ PUMP INSTALLATION l� SYSTEM REPAIR C-) OTHER O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES __ DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TY f OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C �, fl industrial Open Bottom O Manteca Dia. of Well Excavati n Dia. of Well Casing D 14"6omestic/Private Ll Gravel Pack L7 Tracy Type of Casing e-e- Specifications I•l Public I l Other 171 DDee to Depth of Grout Seal d Type of Grout f�)ZLif 1 1 Irrigation Approx. Depth �� ,1,,+t Eastern Surface Seal Installed by Repair Work Done U Type of Pump "rte H.P. o State Work Done _ Well Destruction O Well Diameter Sealing Material 6 Depth Depth Filler Material b Depth TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permuted if public sewer is available within 200 feet.l 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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Cl Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE L No. & Length of lines _ Total length/size FILTER BED CI Distance to nearest. Well _ Foundation Property Line _ SEEPAGE PITS 11 Depth _____Size _ _ Number L� .� SUMPS LI Distance to nearest: Well _ Foundation _- Property Line I� DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance will) 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." The applicant must call for all r urred inspections. Complete drawing on (av/erlse side. ,' Signed X �C /�T�PJ _ Title: ��i// c-c�� — Date: O RTMENT USE ONLY Application Accepted by Date U Are Pit or ro t Inspection by l c` Date �.L q Final Inspection by / �('��` Date _ 1 i Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Servlcee 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED —CASH 10) _ RECEIVED BY DATE PERMITTNO. ra.EH 1324(REV.rin 5) EH 1 26 1 JO 1os _06 0— :