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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 O BOX 2009, STOCKTON, CA 95201 PE MT j` EXPIRES 1 YEAR FROM DATE ISSUED �,{(� (Complete in Triplicate) �'�H Application is hereby made to San Joaquin County for a permit to construct and/or install the work hetelo de�.14T66 This application is made in compliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and RegulatY�ple f San Joaquin County /Public ^Heaalth Services. .�' A� 1jp�CJ�J /k () lr�l�/CNN rl.!/ . City" Lot Size/Acreage 0,0/1 Job Address �� ,�ll Owner's Name `'r'r'L� Address r` Phone r17 . Contract Address/. v`.g" !(A / License No.,-5 1_2`6 Phone —20 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 FLD. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'I Public 17 Other fl Delta Depth of Grout Seal Type o1 Grout I I Irrigation —Approx. Depth I I Eastern Surface Soul,Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material III Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ DDITION5Z DESTRUCTION 11 (No septic system permitted it public sewer is available within 200 feet.) Installation will some: ResidenceCommercial_/Other Number of living units: _L_ Number of 00ms � J Character of soil to a depth of 3 feet: L 'v-� -�, Water table depth T SEPTIC TANK ❑ Type/Mfg .t-� �ti. Capacity��tcri— . No. Compartments z PKG. TREATMENT PLL ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING UNE ❑ No. & Length o1 lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property.Line r SEEPAGE PITS Depth ��Size rmber nearest:SUMPS LI Distance to Well Foundation-/— Property Line 6L __ DISPOSAL PONDS ❑ 1 hereby certify that 1 have prepared this applicatlon 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 cenifies 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 m $U t cit for all eq ued 'nspections. Complete drawing on reverse I e Signed 7 _ Title: � - - Date: FOR DEP TMENT USE ONLY i Application Accepted by Date �r ��`,,// Area 61 `" Grout Inspection by ate Final Inspection by ata Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, f}tvlroomental"Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE FO AMOUNT DUE AMOUNT REMITTED CKCASH RECEIVED BY DATE PERMIT N0. . ER 13-24[REV.It. 5 f' IL',o-ci &,a: